PREFACE TO THE SECOND SERIES.
The study of Skin Diseases without cases or colored plates is like the study of oste.
ology without bones, or the study of geography without maps. However comprehensive
or practical a text-book may be, its verbal descriptions cannot compare in value with a
sight of the thing described, or, what is next best, its faithful representation
It is now eight years since the publication of the first edition of " Photographic Illus-
trations of Skin Diseases." The extensive sale of the work in this country and its
translation and sale abroad have been largely owing to the fact that it is the first atlas
in which the recent and improved photographic processes have been employed in the
portrayal of diseases of the skin. A continued demand for these plates is considered by
the author as not only an evidence of their value and adaptation to the wants of the
general practitioner but also an ample excuse for a new and improved series.
In the present work many of the illustrations have been doubled or trebled in order
to show different jihases of a given disease. In the text, which has been increased to
over two hundred quarto pages, special attention has been devoted to the diagnosis and
treatment of skin diseases, and the work is now presented as a combined atlas and text,
book.
As heretofore, the plates are made from photographic negatives taken from life.
The Artotype reproductions of these negatives are the work of Mr. Edward Bierstadt,
and the hand-coloring of the plates has been entrusted to the well-known medical artist.
Dr. Joseph Gtertner.
GEORGE HENRY FOX
\8 East Thirtj-.first Street,
Neav York,
CONTENTS.
D1SGA.6ES
CHAPTER I.— Glandular Diseases
Seborrhoea .....
Comedo
Milium ....
Cystis sebacea
Hyperidrosis
Bromidrosis
CHAPTER II.— I.VFLAMMATOKT
Rubeola.
Rubella ....
Scailatina
Variola ....
Vaccinia
Varicella ....
Erythema simplex .
Erythema intertrigo .
Erythema multiforme .
Urticaria ....
Dermatitis
Eczema ....
Pityriasis
Dermatitis exfoliativa
Psoriasis
Miliaria ....
Lichen phitius
Lichen ruber
Lichen scrofulosus
Prurigo ....
Herpes
Zoster ....
Pemphigus
Acne vulgaris
Sycosis.
Porr-go ....
Erysipelas
Furunculus
Carbunculas
Ulcus ....
Onychia
CHAPTER III —Hemorrhagic
Purpura
Scorbutus .
CHAPTER IV - »KETBorn!c
Nkvus pigmenlosns
Lentigo
Chloasma ....
Callosilas
Diseased
DiSBASKS
FAGB
rAbl
9
Clavus
121
9
Verruca
. 122
13
Mollu-scum ....
124
15
Cornua cutanea ....
. 126
16
Ichthyosis
127
17
Keratosis pilaris ....
. 130
18
Morpha'a .....
131
21
Scleroderma .....
. 131
21
Elejihantiasis ....
133
22
Rosacea .....
. 134
o<>
Hypertrichosis
136
24
Onvcliau.xis .....
. 138
27
CHAPTER V. — Atrophic Diseases
140
28
Albinisinus .....
. 140
30
Leucoderma ....
141
33
Canities .....
. 143
34
Alopecia
143
39
Alopecia areata ....
. 145
43
Atrophia pilorum
147
43
Trichorcxis nodosa.
. 147
75
Atrophia cutis . .
147
7G
Onychatrophia ....
. 148
78
CHAPTER VI.— Neoplastic Diseases
149
84
Cicatrix
. 149
85
Keloid
150
87
Fibroma .....
. 152
88
Xanthoma .....
154
88
Neuroma
. 155
90
Telanfjiectasis ....
15i
92
N.TJvus vasculosus .
150
93
Angioma
159
95
Lupus vulgaris ....
. 160
103
Lupus erythematosus .
163
105
Scrofuloderma ....
. 165
106
Syphilis . • . . .
107
108
Lepra
. 176
109
Epithelioma ....
180
110
Sarcoma
. 180
112
CHAPTER VII.— Nkueotio Diseases
183
114
Pruritus .....
. 185
114
Dermatalgia ....
185
116
CHAPTER VIII— Para.mtk; Dikkahes
117
Favus .....
189
117
Trichophytosis ....
. 191
118
Chromophytosis
196
119
Scabies ......
. 198
120
Phtbeiriasis
200
fjf
PHOTOGfiAPEIC ILLUSTEATIOIS
Of
SKIN DISEASES.
BY
GEORGE HENRY FOX, A.M., M.D.,
Clinical Professoi' on Diseases of the Skin, College of Physicians and
Surgeons, New York ; Professor of Diseases of tlie Skin, Post-
Graduate Medical School and Hospital, New York;
Physician to the New York Skin and Cancer Hospital ;
Fellow of the American Academy of Medicine ;
Member of the New York Derniatolgical
Society, the American Dermatological
Association, etc.
NEARLY ONE HUNDRED PHOTOGRAPHIC CASES FROM LIFE,
COLORED BY HAND.
SECOND SERIES.
NEW YORK :
E. B. TREAT, 771 Broadway.
1889.
COPYRIGHT,
GEORGE HENRY POX,
1879.
E. B. TREAT. NEW YORB
3S85.
[AU. rights BISEEVED.l
?
Autotpe SAjnrEt Stodber,
Bdwari. n.EPWMn. Stkreottper^^
New York. « »"■ Street, N. \.
LIST OF ILLUSTRATIOl^S,
WITH NOTES OF CASES.
I. Seborrhcea. — J. S., set. 18. Patient
of Dr. F. T. Brown. The eruption of six
mouths' staudiug began upon the nose in the
fi/rm of fine red blotches, upon the surface of
■which a soft yellowish crust developed. This
showed a disposition to return quickly when-
ever it was removed, until application of tar
effected a cure 9
II. a. Varicella.— Patient of Dr. G.
W. Eobiuson, at the New York Dispensary
5. Variola. — From a photograph fur-
nished by Dr. W. 0. Cutler, of Chelsea, Mass. 21
III. a. Erythema esfoliativum. — For
full report of case see page 31.
J. Erythema BTTLLOSUM. — H. B., set. 15.
Photograph taken on the tenth day of the
eruption which ran its course in three weeks.
Subsequent eruptions occurred in this pa-
tient at intervals of one or two years . . 31
IV. Erythema multiforme. — Patient
sent by Dr. Few<mith, of Newark, to the Skin
Clinic of the College of Physicians and Sur-
geons. The case presented a most striking
appearance and illustrated an unusual com-
bination of the niarginate, annular, vesicular
and bullous lesions of multiform erythema.
The disposition of vesicles to form concentric
circles is well shown upon the arm and near
the timbilicus and constitutes what has been
designated " Herpes iris." Upon the ijreast
the coalescence of the ring of vesicles has
formed an annular bulla, a lesion which is
very rarely observed . . . . .35
v. Urticaria. — Patient of Dr. Sherwell.
A yotmg woman, thin, ansemio and nervous,
who had suffered for years from an almost
constant tirticaria. Her skin, at first glance,
appeared normal, but examination quickly
revealed the fact that the slightest external
irritation would produce a marked conges-
tion, while a scratch or trifling blow would
quickly evoke one or more distinct wheals.
In the photographic gallery the operator
focussed upon the smooth skin of the arm and
while preparing his p'ate I traced with a
w.)oden tooth pick, the letters which are
seen in the illustration. By the time the
photographic plate was in tiie camera and
ready for exposure, these letters stood out in
bold relief, in the form of white linear wheals
apon a bright red background . . .39
VI. Urticaria piomentosa. — J. W.,
set. 5^. Eruption appeared first at 18 months
of age as '"hives," but the lesions became
dark and persistent. Very slight improve-
ment under treatment ..... 41
VII. a. Derm.vtitis calorica. — J. N.
A young man had his fingers frost-bitten, and
soon after applied to an apothecary who gave
him tincture of Arnica to apply. Within fif-
teen minutes the fingers began to swell and
large bullae formed. Ulceration occurred in
this case after the dead epidermis was re-
moved.
h. Dermatitis venenata. — This photo-
graph was taken of the fore-arm of a man
who had worked in the woods and evidently
come in contact with poison ivy. The skin
was greatly swollen and covered with fine
aggregated vesicles 43
Vill. Eczema erythematoscm. — M. L.,
set. 66. The eruption in this case was of two
years' standing, having nearly disappeared in
the summer, but occurring in a most annoy-
ing and obstinate form during the winter
months. It had always been dry upon the
face although there coexisted a moist eczema
of the leg. The itching of the face was ter-
rible and local applications failed to subdue
it except when combined with free purgation
which tended to lessen the congestion of the
skin and thus afforded relief . . . 4»
IX. Eczrma rcbrum et squamosum. —
The legs of this patientwere in asimilarcon-
dition until a few minutes before the photo-
graph was takeu. The scales from one leg
were then removed by vigorous friction with
green soap, and a smooth, red, angry-looking
skin expo-!ed; numerous ragged rents in the
tense epidermis are plainly seen . . . 53
X. EczEM.s SQUAMOSUM. — a. J. Z. , set. 20.
Eruption began asanacuteeczema. Amisture
of lime waterand linseed oil, equal parts, was
freely applied, and the arm placed in a sling.
b. This case illustrates a rare papilloma-
tous condition of the .skin which is usuallv
observed u|)0u the lower third of an eczenia-
tous leg (Eczema verrucosum). Above, the
ordinary squamous form of the disease is seen 67
XI. Eczema intertrigo. — Mrs. B., set.
4G. Suffered for three months from inter-
trigo of axillary, sub-mammary and inguinal
(5)
LIST OF ILLUSTRATIONS.
regions. An eczematous condition of the
patches gradually developed and assumed a
distinctly marginate character . . .61
XII. Eczema faciei. — In the first illus-
tration, a baby seven months of age, the in-
flamed and excoriated skin is shown. Tho
second illustration, of an older child, presents
a similar eruption covered by a thick crust.
(Eczema impetiginosum.) . . . .65
XIII. (7. Eczema barbje. — In this case
there was a profuse watery discharge which
dried and formed thick, blood-stained crusts.
The eruption showed a predilection for hairy
parts, altliough occurring also behind the
ears.
b. Sycosis BARB.a. — In this case the in-
flammatory process was deeper seated, involv-
ing the hiiir follicles and producing an erup-
tion of n inierous aggregated pustules.
c. Trichophytosis bakb^. — The para-
sitic source of the sycotic inflammation
in this cae is shown by the number of cir-
cnmscribeil ]iatchcs and by the well-marked
ring upon the neck 67
XIV. a. Eczema squamosum, b. Syph-
ILODEKMA squamosum. — There is scarcely
a cutaneous lesion of syphilis so difficult to
be distinguished from, and so likely to be
confounded with eczema, as the squamous
eruption upon the palms and soles. The
tendency of eczema to fade away at the mar-
gin of the patch and of syphiloderma to
spread with an abrupt margin and to heal in
the centre, is shown by contrast in this illus-
tration 69
XV. Dermatitis exfoliativa. — A
young woman at the Skin and Cancer Hos-
pital who .suffered from an acute attack with
complete recovery in three months . . 73
XVI. Psoriasis guttata. — W. S., sat.
25. Eruption has persisted for eight years,
nearly disappearing during summer months 76
XVII. Psoriasis nummulata. — This
form of the eruption often succeeds the gut-
tate form. Many of the discs show a tendency
to hf al in the centre 77
XVI II. Psoriasis ANNULATA.— This case
shows both scaly rings and the gyrate bands
of scales which are frequently seen at the
margin of a large pigmented area from which
the active eruption has disappeared . . 79
XIX. PsOBiASiSDiFFUSA.— Patient of Dr.
L. D. Bulklev. In this ca.se the scales had
been removed leaving smooth, red, infiltrated
patches with an elevated border. Upon the
forehead the eruption is seen in a character-
isiie jfication ...... 81
XX. Psoriasis makuum et pedum. —
This patient had suffereil for many years fiom
recurrent attacks of general psoriasis. The
(6)
rarity with which this disease aSects the
palms and soles, even in cases where the
eruption is very extensive upon other parts,
has led some (myself among the number)
to deny its existence in these localities. That
it may occur upon the palmar and plantar
surfaces in an exceptional case is shown by
this plate
XXI. a. Pityriasis circinata. — In this
case, as in the illustration, the strong resem-
blance of the eruption to ordinary ringworm
was very marked. The sudden development
of hypersemic patches, the irregularity of the
border and absence of vesiculation. the tawny
color of the epidermis and slight tendency to
a steady increase in size were considered to
be distinguishing features.
b. LiCHEX PLANUS. — The eruption in this
patient had existed for three months and was
confined chiefly to the forearms. The patches
were diffused and very irregular in outline
and there were but few of the characteristic
isolated papules ......
XXII. Lichen ruber. — In this case the
eruption began on the extremities in the form
of acuminate red papules mostly surmounted
by fine scales. These lesions increased rapidly
in number until the entire surface of tho
skin was involved .....
XXIII. Herpes facialis. — Patient of
Dr. G. T. Jackson. Eruption was preceded
by vomiting, chill and fever. It lasted about
ten days
XXIV. a. Zoster frontalis. — Patient
photographed on the eighth day of the
attack. There had been tenderness of the eye
and one-half of forehead and scalp for three
days before the appearance of the first. patch
over eye-brow. The eruption extended back
upon the crown of the head and was accom-
panied by swelling of the cervical glands.
The use of galvanism relieved her suffering
considerably and the eruption ran its course
in less than three weeks.
b. Zoster LUMBOCRURALis. — In this case
the eruption was quite extensive upon the
lower portion of the abdomen and upon the
thigh. Phosphide of Zinc was given without
any positive result
XXV. Pemphigus. — A patient at Bolle-
vue Hospital, under treatment for cerebral
syphilis. A very large tense bulla upon tho
back of the hand had just broken before
photograph was taken, exposing a raw sur-
face
XXVI. Acne.— The first illustration
shows a well-marked pustular acne with some
induration of the lesions. It occurred in a
strumous subject with a poor circulation and
worse digestion.
■^
85
87
89
9.3
95
LIST OF ILLUSTRATIONS.
The second illustration shows the erup-
tions as it so frequently occurs upon the back 101
XXVII. PoRRiGO. — The child whose
hands are shown in this illustration presented
an eruption upon the face as well, consisting
of flattened vesico-j^ustules with a depressed
centre and some tense hemispherical purulent
bulla3. These lesions upon drying, became
covered by yellowish or dark-colored crusts,
which when scratched off exposed a red, raw
surface. The young man whose fore-arms
are shown presented another phase of the
same disease. In his case the lesions dried
into thick yellowish crusts, and wherever the
skin was excoriated by the finger-nails, new
lesions developed, showing plainly the con-
tagious nature of the purulent secretion. This
patient was under the care of Dr. G. T.
Elliot at the Skin and Cancer Hospital . 105
XXVIII. Purpura. — These illustrations
show the eruption in the form of small
petechise and larger ecchymoses. In the
second case there was considerable oedema
and tenderness of the legs .... 115
XXIX. a. OoRNUA CUTANEA. — This
patient had a cutaneous horn u])on the cheek
about an inch in length and of a dirty yel-
lowi.«h hue. It has existed for several years
and had fallen off repeatedly only to develop
again. Near the eye was a lesion resembling
a small sujierficial epithelioma which also
showed a tendency to form a horny excres-
cence. Tlie growths were removed by the
curette and did not return.
b. Keratosis FOLLicuLARis. A patient
of Dr. P. A. Morrow exhibiting a very un-
usual development of small spinous projec-
tions from the follicles on various portions of
the body. (See Journal of Cutan. and Ven.
Diseases, Vol. IV.) 127
XXX. Ichthyosis. — These cases of
ichthyosis simplex were congenital, compara-
tively well in summer, and did not affect the
general health of the patients. In the first
illustration the roughened epidermis is well
shown, while in the second, the cracking of
the skin into polygonal scales is quite appar-
ent upon the thighs 139
XXXI. Elephantiasis. The first case
was a patient of Dr. P. L. Schenck, of Kings
County Hospital. Age 19. Lower extremi-
ties enlarged since childhood, following post-
scarlatinal oedema. Ulceration and slough-
ing took place in this case, the health failed
and death from exhaustion followed.
The second illustration shows a similar
affection of the fore-arm in a milder degree.
A report of ihis case will be found in the
Journal of Cutaneous and Venereal Diseases.
May, 1885 133
SviMiiLTS; lorimary lesions, two cases . 107
XXXII. EosACEA. — a. Case showing
indolent red nodules upon the forehead,
cheeks and chin. Very slight tendency to
suppuration. No functional disturbance ol
the sebaceous glands as is common in pustu-
lar acne.
b. The eruption in this case was inti-
mately associated with intemperate habits
and gastric disorder.
c. Patient of Dr. G. W. French, of Min-
neapolis. The redundant tissue was removed
by excision ■ 137
XXXIII. Leucoderma. — a. An Italian
patient at tlie New York Dispensary. Patches
spreading rapidly.
b. A young man of dark complexion.
The white patches formed a most decided
contrast with the normal skin, especially in
summer 141
XXXIV. Alopecia areata. — a. A
married woman in delicate health. Patch
of six weeks' standing. The application of
compound chrysarobin pigment was soon fol-
lowed by a growth of fine downy hair.
b. A young man working on a farm and
not at all nervous. The disease affected the
bearded portion of face as well as the scalp.
c. In this case the new growth of fine
white hair can be seen upon the affected
areas ....... 145
XXXV. Keloid. The tumor upon the
cheek followed a severe attack of variola.
Patient of Dr. W. T. Bull. The tumor
across the sternal region illustrates a favorite
location of keloid. Patient of Dr. H. G.
Piffard ; that of the srirl followed Zoster. . 149
XXXVI. Fibroma. — These illustrations
contrast the single and pedunculated tumors
with the multiple and sessile growths . 153
XXXVII. Lupus vulgaris. — The patch
upon the cheek of the first patient was of
thirty-four years duration. The ajiplication
of a bichloride of mercury ointment (two
grains to the ounce) was continued for three
months with the effect of making the nodules
smoother and paler.
The hand of the second patient pre-
sented an eruption similar in nature to lupus
vulgaris, though differing in its clinical
aspect. This eruption has been termed
scrofuloderma and tuberculosis cutis . 161
XXXVIII. Lupus erythesiatosus. — J.
C, set. 39. Disease of three years' standing.
The patches on either' cheek were irregular
in form, of a dark orange red hue and cov-
ered with thin scales. Intemperate habits
interfered considerably with tlip tro'itment
of the case but the application of \nv.- car-
bolic acid produced a most decided im;n'ovo-
ment 1^
Sypuilodbrma ; four cases . . .171
G)
LIST OF ILLUSTRATIONS.
XXXIX. Lepra MAcrLOSA. — a. I'atient
of Dr. Sherwell. Boru in the West Indies.
Im|>ioved under treatmeat but died of an
intercurrent disease.
}. P'sease developed during a residence
in Central America. In the first vear dark
red spots appeared on the trunk and extrem-
ities. In the second year the hands became
])ainfnl, the finger-ends swelled and the nails
fell of. In the third year the spots changed
to a light brownish hue and anesthesia be-
came a prominent symptom . . . 177
XL. Lepra tirerosa. — a. A case
showing the tubercular form of the disease
upon the face, and tlie macular form upon
the breast. Patient was an old sailor.
h. This patient contracted the diseasein
Cuba, ■where he lived nine years. It devel-
oped later during a residence in Baltimore.
(Case reported by Rohe in Maryland iled.
Jour., Julv, 1S78. ) Patient died in the New
York Charity Uospital . . . .179
XLI. Epituelioma. — a. Thegrowthin
this i)atient'3 nose was removed by the cu-
rette at the Skin Clinic of the Coll. Phys. &
Surg. In six mouths a small nodule reap-
peared at the border, which being scraped
and cauterized a perfect cure followed.
b. Patient of JJr. E. L. Keyes. The
growth in this case began as iu the last illus-
tration and was allowerl to go untreated.
c. PatieutofDr. F. M. Weld. Showing
the disease in a somewhat unusual location. 181
XLII. Sarcoma. — a. A full account of
this case is given in the first edition of this
work. The disease was of si.K years' stand-
ing, increased rapidly during the year pre-
ceding its fatal termination.
b. Patient of Dr. II. G. Piffard. The
growth in this case was about three inches
in diameter. In the operation for its re-
moval an alarming jiemorrhage occurred.
c. A melanotic sarcoma of the leg devel-
oping upon the site of a pigmentary mole . 183
XLIII. Favi-s CAPITIS. —r?. A patient
at the Skin Clinic of the N. Y. Pi)st-Gradu-
ate Medical School. The buy was born iu
Poland, and like many of the favus jiaticnts
seen in ))ublic institutions of this city)- had
imported the disease.
b. Fa VIS coui'ORi.s. — The arm of a
child showing a reddened and scaly patch
with a group of characteristic yellow, cup-
shaped crusts 189
.XLIY. TRirnopnyxosis capitis et
coRPO«is. — n. A girl with ringworm of the
scalp of recent development.
(8)
J. A boy with large patches of ringworm
of the scalp. The hair around the margin
of the patches had been cut with scissors in
order to show the contrast of the healthy
with the diseased and scaly scalp.
c. A ringworm with concentric circles
occurring upon the forearm of a woman
whose child was suffering from the same
disease 191
XLV. Trichophytosis MANus. — a. A
case of ringworm extending over the back
of a child's hand, the advancing margin
being quite abrupt.
b. Trichophytosis cruris. — C M.,
ait. 25. The eruption began a month ago as
a red spot on thigh outlined b}' the contact
of tlie scrotum. The surface gradually as-
sumed a rough, dry, and powdery appear-
ance. While under observation a character-
istic develo])ment of the jiatches took jdace.
About three quarters of an inch beyond the
scaling margin of the patch on thigh a line
of fine vesicles suddenly appeared. In a few
days the enclosed band of smooth skin had
become red and inflamed while the original
patch appeared smooth and slightly pig-
mented . . 195
XLVI. Chromophttosis. — a. Patient
of Dr. A. R. Robinson, showing the punctate
form of the affection of recent development.
The man was strong and healthy in other
respects.
b. A delicate and phthisical female with
large marginate patches which had persisted
for sevcr.il years 197
X LVII."^ Scabies. — A patient at the Skin
and Cancer Hospital. The excoriated lesions
constituting the eruption in this disease
might be regarded as an artificial papular
eczema 199
XLVIII. Phtheiriasis capitis. — a.
These illustrations show the characteristic
indications of the presence of lice, viz., the
occipital eczema gluing tlie hairs together,
the swollen cervical glands and the porrigo
or eruption of contagious pustules upon the
neck.
b. Phtheiriasis corporis. — A patient
at the New York Dispensary. This was a
tramp, who for some time had been a nightly
guest in a crowded police station-house, and
whose clothes had probably not been removed
for months. They were infested with pedi-
culi, and his body was covered with excori-
ated ]iupules and scratch marks. The illus-
tration siiows the characteristic location of
the eruption between the shoulders and the
]iarallel scratches, ])roduccd by a vigorous
use of the finger-nails .... 201
SEBORRHCEA.
loirPE, E. BiensTAor
DISEASES OF THE SKIIT.
CHAPTER I.
GLANDULAR DISEASES.
The sebaceous and perspiratory glands of the skin are numerous, and called upon to play
an important part in maintaining the health, not only of the skin, but of the whole economy.
A disturbance of their functional activity gives rise to a series of affections which are gen-
erally annoying, and often of serious import as indications of constitutional disease. In
various affections of the skin the glands are incidentally involved, and often become the seat
of inflammation and organic change. liut in the present Chapter the affections resulting from
purely functional derangement will alone be considered.
The natural secretion of the glands may be abnormally increased or deficient in amount.
It may be changed in character and retained within the gland or its duct. Inflammation is not
an essential element of these affections, although it may be present in some cases. Acne, a
disease of the sebaceous glands which is always inflammatory in character, wiU be considered
among the other inflammatory affections.
SEBORRHCEA.
Synonyms — Ac?ie sehacea. — Dandriff.
Seborrhoea is an affection in which the natural secretion of sebaceous matter is abnormally
increased. The skin may appear and feel oily to an unnatural degree, constituting the form
of the affection which is known as seborrhoea oleosa, or it may be covered by greasy scales or
friable crusts, to which condition the term seborrhcea sicca is applied. The affection is usu-
ally confined to a limited portion of the skin, and is notably frequent upon the scalp, face,
breast and back. The oily form of seborrhoea in a mild degree occasionally iiivolves the
whole surface of the body.
Seborrltwa capitis. An abnormal increase of the sebaceous secretion is very common
upon the scalp. In infants this is usually a poition of the greasy coating \vhich covers the
skin of the foetus {cernix caseosa), and which, owing to the presence of the hair, is not re-
moved from the scalp at the first washing of the new-bom infant as readily as it is from the
remaining portion of the body. This fatty csoating upon the scalp is apt to increase when strict
(9)
DISEASES OF THE SKIN.— GLANDULAR.
attention to cleanliness is not observed, and assumes in time a dirty yellowisli or bro^Y^i-ll
Ime from the admixture of dust and dirt. It is usually limited to the crown of the head.
When the mother or nurse is imbued with the absurd notion that the removal of this " ci-a-
dlecap" would jeopardize the health or well-being of the infant, it ma j' remain a year oi
two, until it gradually dries and becomes loosened and cast off by the giowth of new hair
In certain cases this greasy crust becomes heaped up in dry, undulating masses, and iu one
case I have seen it in thick masses over the forehead and cheeks as well as upon the cro^ni of
the head.
Seborrhopa ca]>itis occurring in the fonn of a liquid secretion ia adults is rarely objection-
able as the excessive secretion is readily absoi'bed by the hair, but when, as is far more fre-
quently the case, it occurs in the form of a dry scurf, it is apt to produce more or less irrita-
tion of the scalp and to seriously interfere with the natural growth of the hair. This phase
of seborrhoea is extremely common and is well known under the familiar name of "dand-
riff." Numerous fine and dry scales form upon the scalp, especially upon the anterior por-
tion, and occasion considerable annoyance by falling upon the shoulders in a more or less-
copious shower, whenever the head is scratched or brushed. A slight amount of j^ruritus is
commonly present. In certain cases, chiefly in male adults, this diy seborrhoea forms a thick
crust which welds the hair together upon the surface of the scalp and splits into fibres some-
what resembling asbestos when the hairs are forcibly drawn apart.
Seborrhoea faciei. In yoimg persons, particularly those subject to acne, an oily condition
of the forehead and nose is not uncommon. In rare instances the affection exists in such a
ma rived degree that the oil wUl collect in drops upon the surface of the skin. In the diy
foim seborrhoea is most apt to occur in the vicinity of the eyebrows and upon the bearded
iwrtion of the face, and usually in connection with seborrhoea capitis. Upon non-hairy por-
tions of the face it is most likely to be located in the furrows at the base of the alcB nasi,
whence it may extend upon the sides of the nose and upon the cheeks. It now forms a dirty
crust beneath and around which the skin is sometimes considerably inflamed.
In elderly persons with a wrinkled and discolored skin seborrhoea often appears in the
foiTn of small, dry and dark crusts, especially upon the forehead, temple or malar region.
Wh(m this crust is removed a red and sometimes a raw patch is discovered. These patches
often iiroduce a faintly marked cicatricial condition of the skin, and may become the seat of
lupus or epithelioma. Upon other portions of the body, seborrhoea is frequently met with.
Over the sternal and inter-scapular region it is common in the oUy form and occasionally in
the fonn of pinkish marginate patches covered %vith thin greasy crusts. In the region of the
clitoris and the coronal furrow of the glans penis it is often present, and when frequent
abhition is neglected, it often results in a disagreeable accumulation of smegma and a conse-
quent balanitis or vulvitis.
Di.\o.\osis. The oily form of seborrhoea is not readily mistaken, but the dry fonn of
1 he affection, whether occurring upon the scalp, face or body, is apt to be confounded with
several other diseases. In seborrhoea of the scalp the diagnosis is not always an easy matter.
(10)
SEBOREHCEA.
-he liue oranny scales wMcli constitute "dandriff " are usually of mingled epideiinic M.iics;'
md sebaceous matter, and the relative proportion of these constituents is subject to consider-
able variation. The scales may be very largely composed of dried sebum, in which case the
diagnosis of seborrhoca must be made. But on the other hand, the scales are often dry,
white and powdery, and contain little or no sebaceous matter. In such a case they are the
result of a pre-existing hyper?eniia of the scalp, and constitute that mildest fonn of ery-
thematous eczema which has been described by many writers as a distinct disease under the
name of Pityriasis. It is often difficult, without resorting to a microscopical examination o)
the scales, to decide whether the sebaceous or the epidennic element preponderates, and
many cases indeed are on the border land between seborrhoea and pityriasis.
^\^hen seborrhoea has formed a dry scurf or crust upon the scalp, it bears a strong
resemblance to an eczema which has reached its final or scaling stage. In seborrhoea, how-
ever, the crust can be readily removed by gentle scrai^ing, and the scalp beneath is of a dul!
greyish or pinkish hue, while in eczema the crust is adherent and the scalp beneath it is
more or less inflamed, and apt to bleed if the crust be forcibly removed. In seborrhoea the
affection is dry from the outset, while in eczema there is usually a history of previous mois-
1 ure and a considerable amount of pruritus.
Psoriasis of the scalp is even more similar in appearance to seborrhoea, and is very apt
to be mistaken for it when, as occasionally happens, the scaly patches are not present upon
other portions of the body. But the scales of psoriasis are drier, whiter and less friable than
those of seborrhoea, and while the patches of the latter are irregular in outline, those of the
former are commonly circular and especially apt to occur along the frontal margin of the
scalp, and in the little tuft of hair which extends do^vn in front of the ear.
Seborrhoea faciei may be confounded with eczema, lupus erythematosus and rosacea.
Occurring as it frequently does in the furrow upon either side of the alw na.n, the slvin
beneii ih the crust is apt to become inflamed, but there is never any tendency to moisture, as
in eczema. Extending upon the side of the nose and cheek, the favorite site of erythematous
lupus, an error in diagnosis becomes quite possible, especially as the sebaceous glands are
involved in both affections. But the patches of lupus are characterized by a more chronic
grade of inflammation, a slighter amount of scaling, and by a somewhat marginate outline,
which the patches of seborrhoea never present. Lupus also leads to the fonnation of cicatri-
ces. SeborrhcEa of the nose, occurring in an oily form, is often associated with slight
redness of the skin and hypertrophy of the glands, which produces a notable increase in the
size of the organ. In such a case the resemblance to rosacea is marked, and indeed the two
diseases are not infrequently combined. When seborrhea nasi exists alone there is Uj
capillary dilatation nor formation of papulo pustules ("blossoms") as is common in rosacea.
Moreover the congestion is active and the temperature of the skin is elevated, giving rise to a
burning sensation, while in rosacea, on the other hand, the congestion is passive, the tip o?
the nose feels cooler than natural, however red it may be, and there are no subjectiv
sensations.
(n)
DISEASES OF THE SKIN.— GLANDULAR.
In the very rare cases of seborrhce sicca, involving a large portion of tlie body {S. univer-
salis,) the diagnosis of ichthyosis might be made. The nature of the two affections however
is -widely different. In the former there is an increased secretion of sebum, forming crusts,
which are readily removed, leaving the skin smooth and in an almost nonnal condition. In
the latter there is a lack of fatty secretion. The scales are epidei-mic in character, not readily
removed, and the skin beneath is dry and thickened.
Treatment. If the systemic conditions which predispose to seborrhcea were better
understood much might be accomplished by attention to diet and internal medication. In
the present state of our knowledge we are forced to rely mainly upon external treatment.
There are two objects to be kept in mind in the treatment of every case, viz., to soften, if
necessary, and to remove the sebaceous secretion ; and to stimulate the glands to healthy
action. The first aim can be readily accomplished, the second sometimes proves to be a diffi-
cult task. In seborrhcea oleosa the frequent use of soap tends to keep the skin dry, but
rarely effects a pennanent change in the condition. After bathing the skin with soap and hot
water, and carefully drying it, the application of precipitated sulphur, tannic acid, or some
other astringent powder is usually beneficial. If there be a tendency for thin crusts to form
over the affected surface the foIlo\ving ointment lightly applied, by means of the finger, is
preferable: —
$1. Washed sulphur . . . 8 parts.
Balamof Peru ... 2 "
Petrolatum . . . 40 "
M.
In obstinate cases of seborrhcea of the nose, and these cases are generally obstinate, I
have obtained the best results by having the patient rub the nose vigorously before going to
bed with a soft Unen rag wet ^vith ether, and then apply the following lotion: —
9- Sulphate of zinc ... 3 parts.
Sulphurated potassa . . . 3 "
Alcohol .... 10 "
Rose water to ... . 100 "
M.
In dry seborrhcea of the scalp the crust may be readily removed by soaking it thoroughly
at night \vith olive oil and shampooing the head in the morning with the officinal tincture of
green soap. This will leave the scalp clean and natural in appearance, but a cessation of the
treatment at this point will be speedily followed by a return of the crust. The patient must
therefore be directed to shampoo the head twice every week, or oftener if it seems necessary,
and to apply meanwhile some slightly stimulating omtment every night. Hyde recommends
the following: —
9. OU of sweet almonds . . . 10 parts.
Carbolic acid .... 1 part.
Alcohol to 100 paits.
Oil ol Berganiot ij. s.
(12)
COMEDO.
If this plan of treatment is carried out for a few weeks the tendency to the return of rlie
i-rust will usually cease. In the many cases where seborrhoea does not form a thick ci'iist
upon the scalp, but occurs in the form of dandriff with falling of the hair, it is often neces-
s;ny to prolong the treatment for several months.
COMEDO
Synonyms — Acne punctata niyra — Black heaiU.
Comedo is an affection of the sebaceous glands, occurring nlone or associated with acne.
It consists in an excessive secretion of sebaceous matter, which becoming hardened, produces
a distension of the sebaceous ducts. The skin may be tolerably smooth and dotted with
numerous dirty specks, which indicate the mouths of distended ducts, or, as is usualh' i)ie
case, small conical papules are seen with black dots at their summits. The dark color of
these >' black heads" is owing to the adherence of particles of dirt to the exposed end of the
fatty plug which occupies the follicle. In patients who work in dusty rooms, and especially
among such as are sparing in the use of soap, these black dots increase in number and prom-
inence, until the face looks as though it had been expo.sed to an explosion of gunpowder.
Unna, of Hamburg, claims that the black end of the comedo is not due to the admixture of
dirt, but results from the presence of a pigment. W hen pressure is applied to opposite sides
of a comedo, an inspissated mass composed of sebum and eiuthelial ceUs can be extrnded in
the shape of a curdy or cheesy "worm."
The affection is commonly observed upon the face, although the upper portion of the
back is almost as frequently its seat. Not infrequently a few comedos (or comedones, as they
are called by writers who prefer to retain the Latin term), are seen upon the sternal region
and upon the sides of the neck. The sebaceous glands of the nose, which are numerous and
normally of large size, are not apt to be gi'eatly distended, although in nearly every ca.se of
this alfection white plugs or threads of sebum, an eighth of an inch or more in length, can be
expressed from the follicles, both upon the tip and ahe nasi. In the concha of the ear the
black ends of a group of comedos are frequently seen. In this location they are firmly im-
bedded and pressed out with difficulty. Upon the forehead and temples comedos do not at-
tain as large a size nor are they as numerous as they are upon the cheeks. They may be soft,
whitish, an/l curdy, curling as they are extraded from the sebaceous ducts, or in cases of long
standing iliey may be more or less hardened, of a yellowish color and jjyriform shape, and
when pressure is exerted upon the walls of the follicle by means of a silver tube or comedo-
presser they pop out with an audible sound. Frequently the comedo is found, upon exami-
nation, to be composed of three parts, a black end corresponding to the mouth of the follicle.
a yellowish or homy mould of the duct, and a soft Avhitish extremity representing the fresh
secretion of the gland. Microscopical examination of the sebaceous matter composing the
comedo will sometimes reveal the presence of an animal parasite called the stealozoon or aca-
rus folliculorum. Several of these microscopic insects may be found in one follicle. They are
(13)
DISEASES OF TEE SKIN.— GLANDULAR.
perfectly harmless, and occur in healthy follicles as well as in those which are dislorxled by
an accimuilation of sebum.
Diagnosis. Comedo is not lUcely to be mistaken for any other affection of the skiu, but
in the treatment of acne a peculiar blackening of the mouths of the sebaceous glands is s/)me
times accidentally produced, and this condition may simulate the disease under consideration.
\Vhen ointments or lotions containing lead or mercury have been applied to the face, and a
change in the treatment is deemed advisable, an ointment or lotion containing sulphur is
sometimes thoughtlessly prescribed by the physician, or foolishly applied by the patient with-
out authority. Under such circumstances, a chemical combination of the sulphur with the lead
or mercury takes place, and to the patient's dismay, the face suddenly assumes an appearance
as undesimble as it is unexpected. The cheeks, and especially the nose, becomes peppered
\y\x\\ innumerable black dots, each one indicating the orilice of a sebaceous follicle, at which
point the above mentioned chemical combination has taken place.
Treat JiENT. The treatment of comedo is usually restricted to local measures, although
attention to the state of the general health is necessary in most cases to check the tendency
to the disorder. Our first aim should be to evacuate the distended ducts. This is frequently
accomplished by the patient, by means of the thumb-nails. The use of a watch-key is a bet-
ter plan of treatment, but since, on account of its square bore and rough end, it is liable
to wound the skin, several little comedo-pressers have been devised as a substitute. The
simplest instrument is a silver tube, live or six centinieti-es in length, Avith rounded extrem-
ities, and a calibre of knitting-needle size. By placing the end of this tube over the summit
• >f the comedo, and exerting a quick, firm pressure, the sebaceous pliig can be expressed with
tile least amount of discomfort. In pressing out comedos over bony prominences, such as^
lh<- cheek bone or margin of the jaw, or upon the nose, care must be exercised lest the tube
slip ami tear the surface of the skin. A small elongated curette can often be used to better
advantage than a silver tube, especially when the comedos are large or of variable size. The
bealc of the curette, which is held at an angle of forty-five degrees, should be pressed firmly
ui)c>n the sldn at the side of the follicular orifice, and by performing a sort of tour de maiire
with the instrument kept at the same angle with the skin, pressure is successively exerted
tipon each side of the comedo and its easy extrusion from the duct is thus accomplished. In
this as in other simple manoeuvTes, practice makes perfect. When the comedos are consid-
erably elevated above the level of the skin, the black head may be scraped out of the duct by
a rapid sweep of the side of the instrument, after which a natural evacuation of the gland
will soon follow. After the follicles have been evacuated, the face may be bathed with very
hoi wati-r to lessen the congestion, which, in a greater or less degree results from the use of
any iiitrunient. The daily use of soap should be prescribed, both for the sake of its stimulant
.iftidii oil the gland^i, and for the purpose of removing a portion of the fatty matter from
.|ii<-i> wliich are not sufficiently distended to warrant the use of the comedo-presser. Soap
uill alN«, remove from the follicular orifices the numerous black specks which in young persons
wi.li ovt-r-activp glands, ai'e apt to dot the face in spite of unremitting attention to bathing.
(11)
MILIUM.
When there is any tendency to glandular inflammation, and the use of soap is found to ag-
gravate this, it is well to bathe the face in warm water, to which a little borax or bran may
be added. Ladies sometimes object to the use of soap in bathing the face, on account of the
tense and shiny condition of the skin which is sometimes left. This is easily remedied by
slight friction with a piece of flannel or chamois-skin, and if necessary, by the application
of a little rice powder or lycoiwdium. As a lotion to be used in cases of comedo, the follow-
ing is mildly astringent and conducive to the normal action of the glands :
];l. Sulphate of Zinc, .... 2 parts.
Orange Flower Water, . . 100 "
M.
On the theory that the black head of the comedo is due to a pigmentary deposit which
is soluble in acids, Unna advises tlie use of the following ointment :
9. Kaolin, 4 parts.
Glj'cerine, 3 "
Acetic Acid, 2 "
M.
MILIUM.
Synonym — Acne punctata albida.
Milium is a distended sebaceous gland, forming a minute whitish tumor of the skin. It
is usually of the size of a pin's head or a mQlet seed, from whence it derives its name. It
presents the appearance of a little pearly globule just beneath the epidermis, and has a fine
shotty feeling when the finger is passed lightly over the skin. A number are commonly pres-
ent in a given case, and are most frequently found upon the eye-lids and the malar portion of
the cheek. They are most apt to occur in middle life and in women ^^ith a dark sallow slcin.
They form gradually and for some time may escape notice. They cau.^e no subjective sensa-
tion whatever, and often remain for years without undergoing any ch.\uge in size or appear-
ance, and it is only in certain cases where their number renders them •conspicuous, that the
physician is called upon to remove them. When carefully examined after removal from the
«kin, nulia are found to be small globular masses of a dense cheesy or calcareous character.
They are fomied by the retention of sebum in the glands, the duct of which h.\s become ob-
literated.
Diagnosis. Upon the forehead and temples of young persons suffering from acne,
^.amerous whitish punctate elevations of the skin are often present in connection with come-
dos and acne papules. These are also distended sebaceous glands, shining through the thra
epiati-mis, and differ from milia only by the fact that the duct is not obliterated. ^\Tiile
milia are disposed to be permanent, these little glandular nodules usually become emptied of
their contents in a comparatively short time, even without treatment.
Trf ktment. The simplest and best mode of removing milia is to punrture the epi-
(15)
DISEASES OF TEE SKIN.— GLANDULAR.
deniiis over each one with a sharp acne lance, and then to press out the little globular tumor
by means of a small sized curette. This need not cause the slightest drop of blood and is
sufficient to permanently remove the milium. I have never seen one return after removal in
this manner.
CYSTIS SEBACEA.
Synonym — Wen.
A sebaceous cyst or wen is a milium oq a larger scale. It is a collection of sebaceous
matter enclosed by a sac which has been formed by a gi-adual distention of a sebaceous gland.
It forms a prominent rounded tumor, varj-ing in size from a pea to an English walnut. "When
small, wens are usuaUy of linn consistence, and movable beneath the skin. When larger,
they are apt to become somewhat softer and doughy in character. The skin over the tumor
is usually of normal color and texture. It may become somewhat thinner when thegro^vth is
large and in exceptional instances it becomes reddened by inflammation, and suppuration
occasionally occurs. "Wens are usually single, but several of varying size are not infrequently
met \v\x\\ upon the same patient. The scalp and forehead are the favorite site of the tumors,
but they also occur upon the back, the scrotum and other parts. A cyst occvu-ring upon
hairy portions of the body usually becomes bald in a short time, the hair bulbs being de-
stroyed by the tension of the sldn. Occasionally the duct of the gland is not entirely obliter-
ated and through this canal leading to the cavity of the cyst, a portion of its contents is from
time to time extruded, giving the tumor a flattened appearance.
The contents of sebaceous cysts vary in character from a soft, white, curdy matter to a
diy, friable and sometimes extremely fetid substance.
Diagnosis. A wen is usually recognized \vithout difficulty, but a fatty tumor (ade-
noma) or even a subcutaneous abscess might be mistaken for it, especially when not occurring
upon the scalp.
TuKAT.MK.vT. A Complete removal of a sebaceous cyst is usually not a difficult matter
if ordinary care is exercised in the operation. The skin covering the tumor should first be
incised to a sufficient length to allow the globular mass to pass through readily. This can
then be easily raised from its bed by means of a curved spatida or small spoon handle, as
there are usually no adhesions, except in cases where there has been a previous unsuccessful
operation or spontaneous inflammation around the tumor. Care should be taken not to cut
into the sac and allow a portion of its contents to escape. If the sac is merely opened and
its cheesy contents scraped or pressed out, a return of the tumor may be expected. Our object
should be to remove the whole or greater portion of the sac, and when this is accidentally
punctured by the knife, and the tumor becomes partially collapsed through loss of some of
its contents, it is more difficult to get rid of the entire growth. Some prefer to puncture a
Aven, i>ress out the contents and destroy tlio socretinrr surface of the ?ac by injecting iodine or
carbolic arid. Vid.-il Ims iidvised ihc injection of Imhii live to ten di-opsoC eth«'r every second
(IG)
UTPERIDROSrS.
thiy until inflammation ensues. Then a puncture of the base of the tumor will allow pus ajiJ
broken down sebaceous matter to escape, and a cure follows.
HYPERIDROSIS.
lI\-Iieridrosis is an affection in which there is an abnormal functional activity of the
sweat glnnds. Profuse perspiration which follows vigorous exercise or exposure to a high
temperature is purely physiological in character and consistent with health. The col-
liquative sweating of phthisis as also that which is observed in rheumatism, intermittent
fever and other febrile affections, is strictly speaking an instance of hyperidrosis, but is
usually not considered when viewing the condition from a dermatological standpoint. Many
who are otherwise in apparently perfect health sweat excessively without apparent provoca-
tion, and are annoyed thereby to a greater or less degree. Corpulent people, especially in
summer time, are especially prone to a mild degree of hyperidrosis, but some who are not
particularly well nourished si.ffer in like manner and at various seasons of the year. Tlie
affection may occur in an acute form and subside in a short time, the obscure cause having
ceased to act, but generally it is extremely chronic, as the disposition to the excessive secre-
tion of sweat is not easily subdued.
Hyi^eridrosis may be general (//. imi car sails) or local in its manifestation {H. localis).
Occurring over the whole surface of the body it is not usually severe, but when limited to
certain parts it is much more noticeable and constitutes a not uncommon and an extremely
disagreeable affection. The palms, soles and axillae are the parts which are most apt to be
the seat of the trouble, but the face and the genital region are not unfrequently affected. In
rare cases hyperidrosis occurs in a unilateral form. One side of the head, or one of the ex-
tremities, or even one-half of the entire body, may be bathed in perspiration, while the
opposite side retains its natural condition. A story is told of a celebrated young comedian
wlio was subject to unilateral hyperidrosis of the face. One night he appeared upon the
stage as an old man, the face being made up to suit the part. As the play proceeded the
merriment of the audience became excessive, and the unusual and seemingly uncalled-for
shouts of laughter which greeted his acting surprised and peq^lexed him. On retiring behind
the scenes he found that the unilateral iierspiration had washed half of the paint from his
face, which had presented to the audience the appearance of wrinkled age upon one side and
blooming youth upon the other.
Hyperidrosis of the hands is not only annoying to the patient himsell' but to those with
whom the social custom requires him to greet with a shake of tlie hand. A Ivid gk)ve cannot
be worn in certain cases without becoming immediately soaked through by the increaseil
secretion, and often the affection prevents the sufferer from following any occupation involv-
ing the handling of fine textures. Frequent wiping of the hands does little good, and m
social intercourse the consciousness that the hands are unpresentable and the consequeiii
anxiety of mind tend only to increase the unfortunate secretion.
(17)
DISEASES OF THE SKIN.— GLANDULAR.
HjTipridrosis of the feet is often associated with a similar condition of the hand.^, out
either may exist alone, '\^^len the feet are theseat of the affection, the stoc kings, howeTcr
frequently changed, are kept moistened by the secretion, and even the leather covering of the
feet becomes soaked in time. A disagreeable odor is usually occasioned by the chemical
change which the secretion undergoes.
Treatment. The predisposing causes of hyperidrosis should be diligently sought foi
in every case and removed if possible. Nervous derangement and an impaired circulaiioD
are frequently underlying conditions which demand the most careful hygienic treatment.
Among the drugs which have been recommended as cajiable of producing beneficial results in
this affection are atropia and ergot. Small doses of jaborandi have also been employed with
good effect in both local and general hyperidrosis. As it is impossible in many cases to
determine the precise cause of the disorder, we are generally forced to depend largely upon
external applications, many of which give immediate relief and in time subdue the excessive
secretion. When the sweating is general baths containiug sea salt or carbolic acid may be
employed, or portions of the body rubbed successively \vith a soft sponge dipped in the fol-
lowing lotion : —
9 . Sulphate of quinine ... 5 parts.
Alcohol to 500 "
M.
In hyperidrosis of the axilla or genital region, the skin may be bathed %vith a strong solu-
tion of tannin or alum, and after careful drjdng, the following powder dusted over the
surface : —
9. Salicylic acid ... 3 parts.
Starch .... 10 "
Talc powder . . . 87 "
M.
For the hands and feet a similar plan of treatment is useful. Another excellent remedy
is the subnitrate of bismuth rubbed well into the skin after bathing, or dusted over the inside
of the gloves or stockings, llebra advised a plan of treatment, which if properly carried out,
usually affords immunity from the annoying secretion for a considerable time, if it does not
effect a cure. This plan consists in spreading diachylon ointment upon pieces of linen with
which the lingers and toes, as well as the rest of the hands and feet, are carefully enveloped.
This dressing is to be re-applied twice daily for a week or two, the hands not being washed
in the meantime. The application causes an exfoliation of the epidennis, leaving the skin
soft and comparatively dry.
BROMIDROSIS.
Synonym — Osmidrosis.
Bromidrosis is an affection in which the perspiration is characterized by a peculiar and
(18)
BROMIBROSIS.
usually an extremely disagreeable odor. The normal perspiration has always a slight odor
from admixture \vith the sebaceous secretion, although this may not be perceptible to the
average sense of smell, except in summer, or after violent exercise. In disease the perspira-
tion is frequently changed in character, and rheumatism, intermittent fever, scurvy and other
alfections have been supposed by some to have each its distinct and characteristic odor. In-
deed, some have claimed that the odor emanating from various skin diseases, notably small-
pox, scabies and sj'j^hilis, might be utilized as a basis of diagnosis. Certain persons, whose
skin is perfectly free from disease, and whose general condition is good, exhale from their
bodies a peculiar odor which seems to be natural to them. It may be constant, or occur only
in connection vdth mental excitement, or other unusual conditions. The odor is usually in-
describable, although it has been likened in certain instances to "violets," "pine apple," <tc.
In brcmidrosis the secieticn may exist in normal amount or it may be in excess. The
latter is commonly the case upon the feet and in the axilla, in which case we have simply
hyperidiosis with a foetid odor. This odor may not be due to any change in the composition
cf the perspiratciy secretion, but usually results largely ficm the decomposition of the
sweat which has soaked into the clothing of the part. In brcmidrosis of the feet even the
shoes may become saturated with the fotil secretion. The peculiar odor may also be due in
great part to a peculiar secretion of the sebaceous glands which becomes mingled with the
perspiration. As the foetid secietion of brcmidrosis is more irritating to the skin than a
simple excess cf perspiration we find in this disease a maiked tendency cf the skin, especi-
ally cl the leet. to become macerated and tender. Upcn the scles the epidermis is always
sodden, and often peels off in large masses, leaving an inflamed and often eczematous con-
dition, through which locomotion is seriously impaired.
Treatment. The general treatment of brcmidrosis is substantially the same as that
ol hjqieridrosis, since whatevei' lessens the amount of the secretion tends to diminish the
unpleasant odor. The natural tendency cf some persons to secrete fatty acids, which
give tc the mingled sweat and sebum a pungent if not a disagreeable, odor is extremely
difficult to overcome. The more severe forms cf foetid sweating are fortunately more amen-
able to treatment, and are often checked by the adoption of such measures a.s promote the
general health ol the person aflected. In the meantime a resort must be had to local and
more oi less palliative measures. Lotions and dusting powders of an antiseptic character
have been found most useful in brcmidrosis, especially when the disease involves the feet,
as it is most apt to do. Foi bathing the skin a one per cent, solution (five grains to the
ounce) ol chloral oi permanganate ol potash is both cleanly and beneficial. It should be
applied with as little friction as possible, and allowed to dry upon the skin, or the excess of
moisture may be removed by the pressure of a soft warm cloth. Ainsworth recommends the
application of the following powder : —
9. Dried alum ... 46 parts.
Salicylic acid . . . 6 "
M
DISEASES OF THE SKIN.— OLAKDULAR.
TMn, of London, after a careful study of the subject of bromidrosis, found the moist are
which collects in a patient's stocking to be of an alkaline reaction and swarming with bac-
teria. This fluid acts as an initant to the skin and greatly aggravates the disease. As a
parasiticide application, and one calculated to aUay the irritation of the skin, he recommends
the use of boracic acid. The stockings should be changed tv^'ice daily and the stocking feet
placed for some hours in a jar containing a saturated solution of boracic acid. They are then
dried and may be worn again, the odor liaving disappeared. To prevent the foetid perspiration
soaking into the soles of the shoes, and thus giving rise to a pennanent stench, cork soles
are to be worn during the day and soaked over night, like the stocking feet, in the jar of
boracic acid.
Chkomidrosis is a term applied to a discoloration of the sweat. This may be blackish
{melanidrosis) and occur about the eyes of hysterical women, bluish {cyanidrosis) and occur
upon the body in sufficient amount to stain the underclothing, or red {hematidrosis) in which
case there is usually an extravasation of blood into the sweat glands.
Anidrosis signifies an absence of perspiration. It may residt from disease of the skin,
as in ichthyosis, or from internal disease, as in cases of diabetes. For the relief of this con-
dition the internal use of pilocarpine, or a resort to the Turkish bath, would suggest
itself.
(20)
CHAPTER II. i
INFLAMMATORY DISEASES.
This class of skin diseases, including those in which inflammarion is the essential element,
ranks first in point of size and importance. It embraces most ol the common affections of
the skin, and a thorough api^-eciation of the nature and treannent of these will enable the
physician to claim the mastery of more than one half of Demiatology.
Some wTiters have separated the hypersemic affections from those in which exudation is
present, but in practice it is by no means easy to keep them apart. A simple erythema w'uh.
desquamation merges gradually into the mildest form of erji;hematous eczema, and in many
cases it is impossible to say where the dividing line should be drawn. Since an erythema
which is not e\anescent in character is usually accompanied by redness, heat, ])ain and swell-
ing in at least a mild degree, it seems botli jiroper and desirable to include the purely hyper-
lemic with the exudative affections under the same head.
The exanthemata naturally fall in this class, but as they are fully described in all works
on general medicine, it is unnecessary in a treatise on skin diseases to devote much space to
their consideration. ;
t
RUBEOLA.
St/ a onyms — MorlnlU — Mensles.
Measles is a highly contagious febrile affection, the chief symptoms of which are a ca-
tarrhal condition of the respiratory passages and a characteristic exanthem. It is commonly
observed among children, and in an epidemic form. Like the other exanthemata, it is not
likely to occur but once in a lifetime ; but exceptional cases are not infrequent where re])"ated
attacks in the same person have been noted by i)hysicians who would not be likely to nii.stake
the nature of the disease. Measles is more contagious than small-pox or scarlet fever, and
even on i he first day of the fever infection is ai)t to be transmitted to unprotected jiersons
who come near the patient. The period of incubation is variable in duration, ranging from
one to three weeks, during which period the patient experiences little if any discomfort.
The attack begins suddenly with an imtation of the mucous membrane of the nose and suf-
fusion of the eyes, a tendency to sneezing, a slight thin nasal discharge and occasional epis-
taxis. The tem])erature which usually rises to 103-104° F. at the outset, declines on the second
or third day, but rises again with the outbreak of the eruption. This generally occurs on
(21)
DISEASES OF THE SKIN.— INFLAMMATORY.
the fouitb day, sometimes on the third, but occasionally on the fifth day or even later. It is
lii-st noted upon tlie forehead and temples, from which it quickly extends down upon the face,
and in two days usually covers more or less of the trunk and extremities. In its natural
course the fever now abates, the catarrh and cough are lessened, the rash gradually fades,
and in less than two weeks the skin presents a characteristic branny desquamation.
The eruption is at first of a dusky hue and of a maculo-papular character. The lesions
are numerous and closely aggregated over limited portions of skin, darkest in the centre, but
disapjiearing entirely under pressure of the finger. Tliey are sometimes crescentic in form,
but usually appear as a deep red and fine mottling ujion a swollen and erji;hematous surface.
The disease may occur without the catarrhal symptoms, and on the other hand without
the appearance of anj' rash, or one so slight as to escape observation. In rare instances,
which occur chietiy among poorly nourished and weakly children, the eruption becomes
hemorrhagic in character, and the disease assumes a malignant fonn (Black Measles). When-
ever the eniptiou is very well marked there is liable to be a development of fine miliary ves-
sicles upon some portions of the skin. Occasionally bullse form, and frequently urticaria
appears as a complication of the rash.
RUBELLA.
Synonyms — Rotlum — German Measles.
This affection is one v>-hich was formerly regarded as a mild form of rubeola, and even
now is often mistaken as such. There is little doubt, however, that it is a distinct affection,
and that an attack of the former does not exempt a patient in any degree from an attack of
the latter affection, or vice versa.
Tlie sj-mptoms of rubella are similar to those of rubeola, though far less marked. The
prodi-omic fever is very slight when present, never more than twenty-four hours in duration,
and frequently the rash is the first sjTnptom of the affection. There may be a slight coryza,
with redness of the conjunctiva, but rarely sufficient to occasion much annoyance. A sore
throat is a more common symptom, and one which sometimes persists after the rash has dis-
appeared. The eruption consists of numerous minute red papules, of a much brighter hue
than is seen in measles, and exhibiting a tendency to coalesce and form smooth red patches.
It fades in two or three days and is followed by slight desquamation.
SCARLATINA.
Synonym — Scarlet Fever.
Scarlatina is an acute contagious disease characterized by fever, sore throat, and a bright
red erj'thematous eruption.
The period of incubation is quite variable, and unlike measles, the patient is not likely
to infect others until the eruption has become well developed. The scarlatinal poison is less
(22)
SCAIiLATIN-A.
volatile than that of measles, and is capable of remaining a long time in clot bin"- and other
articles which have been in close proximity to a scarlet fever patient, and this fact -ndll on-
■doubtedly account for the uncertainty of the period of incubation.
The attack, which is always sudden, is usually characterized by chills, vomitin"- and
swelling of the throat. The tongue is at first coated, but in two or three days be"-ins to
assume a characteiistic, bright red 'strawberry" appearance. The fever is of high grade,
and may reach 105°, or more, on the lirst day, the pulse being rapid in character, and the
skin extremely dry and hot. It sulfers no abatement, but on the other hand, may increase
with the development of the exanthem.
The eruption usually appears upon the second day. It is commonly noted first upon the
neck and upper portion of the chest, from which it rapidly spreads upon the trunk and ex-
tremities, reaching its full development upon the third or fourth day. With the exception
■of a bright flush upon the cheeks, the face remains unaffected at the outset of the eruption.
The rash is at first punctate in character, the red points being numerous and closely set, but
hy degrees these coalesce and fonn laige patches of imifonu redness. Upon the neck and
«hest they occasionally become slightly vesicular. Upon the fourth or fifth day the rash
usually begins to fade, and in ten or twelve days has completely disappeared, if the case is
typical in its course. A well marlvPd desquamation of the greater portion of the body then
takes place and continues during the period of convalescence. The flakes of epidermis may
be small though rarely furfuraceous as in measles, but generally they are of considerable
size, especially upon the hands and feet. In some cases the nails and hah- fall after a severe
attack of scarlatina. At the commencement of desquamation, and sometimes earlier in the
course of the disease, the kidneys are notably affected, and albumen appears in the urine in
•considerable quantity.
Scarlet Fever, with all the usual symptoms except the eruption, may occur, especially in
adults. Althoitgh the disease occurs, as a rule, but once in a lifetime, it is not imcommon
for some physicians and nurses to be affected with sore throat as often as they are called
*ipon to attend a case of scarlatina.
There is a great variation in the severity of the disease among individuals and in differ-
•ent ei)idemics. While one child may have scarlet fever and scarcely be aware of the fact,
another may have a malignant form, with terrible throat symptoms and hemorrhagic erup-
tions, or even die before the rash has had time to appear.
L>iAti>rosis. As scarlet fever, measles and rubella do not always occur in a typical
ionn, a difficulty in diagnosis is very apt to arise, especially when the case happens to be a
sporadic one. The features of the three diseases, which have been very briefly mentioned,
must always be taken into consideration as a basis of diagnosis, but experience \vill generally
be found to be the only reliable guide. For convenience of reference the following table^
arranged by Liveing, is appended : —
(23)
DISEASES OF THE SKIN.— INFLAMMATORY.
SCAELATIXA.
IncvJbation, four to six days.
Prodromic fetter^ two days.
Basil : —
(a.) Diffuse bright red, or in large
patches.
(&.) Begins on the neck, then chest,
(c.) Brightest on the covered parts.
Period of Eruption. Uncertain, but gen-
erally rather longer than in measles.
Tongue. Red, with large, prominent pa-
pUlse, "strawberry like," or covered with a
thick, yellowish fur in the centre, with
bright red prominent papillae.
Tliroat. Severely inflamed. TonsUs en-
larged and very painful.
General symptoms. High fever ; hot
skin, high temperature and pulse, headache,
&c.
Desquamation. Copious.
Rubeola.
Fourteen days.
Three days.
(a.) Crescentic
patches of a dull
raspberry red.
(J.) Begins on
the face.
(c.) Brightest on
the exposed parts.
Very constant ; about
three days.
Furred, and often
whitish.
Slight soreness.
Dark red irregular
spots on soft palate.
Swelling of the face
and eylids, coryza, pho-
tophobia, lachrymation,
laryngeal cough, and
general catarrh.
Very slight, branny
Rubella.
Ten to fourteen days.
Often absent.
(a. ) At first,
patches like
measles, subse-
quently often
becoming dif-
fuse like scar-
latina.
(&.) Begins oa
back and chest.
About five days.
Slightly furred.
Slight soreness, but
generally lasting a
long: time. Tonsils en-
Fever generally
slight, with or without
catarrhal symptoms.
Slight. Sometimes
more than in measles.
desquamation.
Treatment. Typical cases of these three affections usually run their course w ithout re-
quiring any inteference on the part of the physician. In the mildest cases, however, a strict
professional watch care is demanded in order to detect all threatening complications at the
earliest i)ossible moment. On prophylactic grounds, complete isolation of the patient is
necessary, and after convalescence a thorough fumigation of the apartment, the bedding and
clothing is advisable. This is especially so in case of scarlatina.
VARIOLA.
Synonym — Small Pox.
Variola is ordinarily the most severe and the most dreaded of the acute exanthemata.
Thanks to one of the most brilliant achievements of medical science, this terrible scourge of
former times can now be held in check, and measures instituted which ^vill exempt all intel-
(igent and unbiased me.'ubprs of n community from its direful attacli.
The period of inniliaJioii is ii.siially from ten to iliirtet>n days, during which siifjhr luii
(•--4)
VARIOLA .
tjuor, with pain in the head and back, may be experienced. The initial and prodromal sia^e
is usually iishered in by a violent rigor or repeated chills. This is followed by a well-marked
fever, severe headache, and aching pain in the lumbar region and vomiting. At this time a
diffuse erythematous rash may appear upon portions of the body, or a petechial eruption be
(observed upon the lower portions of the abdomen, genitals and inner surface of the tliighs.
These disappear before the occurrence of the characteristic exanthem whirh commonly makes
its api)eurance on the third day. This begins upon the scalp ana rorehead in the form of
small pale red and slightly elevated macules. These qmckly ap])ear upon the face, and in a
few hours are apparent upon the body and extremities, the legs :ind feet being the most
affected. In about two days these lesions have devoped into hard shotty pap-ales, which on
the sixth day of the disease become conical and present minute vesicles at their apices. On
the eighth day these vesicles are pea-sized and hemispherical in form. A peculiar depression
in the centre ol most of these vesicles now takes place which is quite characteristic of the
disease. On the ninth day of the disease the lesions become pustular in character and a
congested halo appears around each. ^VTien the lesions are closely aggregated a considerable
tumefaction of the skin ensues, with frequent coalescence of the pustules. The face is espe-
cially apt to present this confluent form of the eruption, and the swelling becomes so great
thni the patient is unrecognizable. Owing to the successive development of the lesions upon
'1 liferent portions of the body the eruj^tion is generally observed to be pustular upon the face,
while it is only in the vesicular stage upon the lower extremities. Even when the eruptiou
is quite discrete upon the trunk, the hands and feet are usually thickly covered and intensely
swollen. The mucous membrane of the oral cavity, and particularly the hard and soft palate
present an eruption somewhat similar to and coincident with that upon the skin.
The temperature, which may have reached 104« in the initial stage, falls suddenly with
the outbreak of the eruption to nearly normal degree, and the other symptoms likemse abate,
leaving the patient in a comparatively comfortable condition. With the development of
pustules a secondary or suppurative fever ensues, accompanied by headache, and not infre-
quently delirium. The pustules of small-pox, which are at first umbUicated, like the pre-
ceding vesicles, may become rounded from a loosening of the trabecular bands, which have
produced the central depression. After an existence of two or three days a partial desiccation
takes place, with an exudation of a viscid, honey -like substance upon the surface of the pus-
tules. Gradually these become converted into brownish crusts, the inflammatory swelling of
the skin lessens in a notable degree and the fever subsides. The crusts loosen and fall, leav-
ing a dull red mark, the color of which varies according to the suri'ounding temperature and
the activity of the circulation. With the drying and fall of the crusts intense itching is
commonly experienced by the patient. In uncomplicated variola the course of the disease is
usually four to six weeks. In complicated cases, or in those rare and malignant cases where
hemorrhage takes place in the pustules, the duration of the disease and convalescence is
greatly prolonged unless, as frequently happens, death cuts short its course.
VARIOLOID. A mild form of small pox, such as may occur in persons whose suscep-
(25)
DISEASES OF THE SKIN.— INFLAMMATORY.
tibUity is slight, or in those who have been partially protected by inoculation or vaccination,
is comiiionly Ivnown as varioloid or inodiiied small pox. It is by no means a distinct affection.
The most strildng feature of varioloid is its tendency to run an irregular course as re-
gards the diiiution of its stages and the character of its symptoms. The eruption, which in
variola vera appears uniformly on the third day, may appear on the first or seco).'5 in vario-
loid, or be unusually delayed. It often appears first upon the trunlc instead of upr// the face,
often in successive crops, and the lesions do not run such a I'egular course as do thof/j of typi-
cal small pox. Frequently the lesions are absorbed before reaching the pustular stage, and
again they may run such a rapid course that desiccation begins on the seventh or eighth day.
DiAGXOSis. The diagnosis of variola or varioloid must always rest upon a familiarity
wth the sjTnptoms of the disease and a very careful examination of the case. ^^Tien doubt
exists it is advisable to visit the patient repeatedly at short intervals, and to avoid g'.nng anv
hasty opinion.
TuEATMEXT. — It has been said of Small -pox that in its mildest forms medi.inal treat
ment is scarcely called for, in the severest it is useless, and indeed under any ciicumstances
it has but little influence over the coiirse of the disease. Nevertheless there is much that can
be done in its treatment ^nth a %iew to alleviating the sufferings of the patient, guarding
against threatening complications, and preventing, to a certain extent, the unsightly pitting
of the face, which is often a life-long indication that the bearer has suffered from small-pox.
There is no specific remedy as yet discovered which will influence the course of the dis
ease, and treatment of the various sjonptoms and complications as they present themselves is
the usual duty of the physician. In no disease is good nursing more essential, and attention
to minute details which contribute to the comfort of the patient will often turn the scale be-
tween life and death. The older plans of treatment by sweating, purging and blood-letting
have fortunately now but an historical interest, and have been supplanted by various hygi-
inic Pleasures, such as keeping the patient in a cool, dark and well ventilated aiiartment, and
such treatment as is calculated to lessen cutaneous inflammation and to support the strength
of the patient. The free use of cold water and acid drinks to allay thirst, and the applica-
tion of cold compresses, or resort to cool baths oi- sponging, are highly recommended. The
application of caustic to the pustules, or the use of mercurial plasters and solutions of iodine
or nitrate of silver, with a view to prevent pitting of the face is of doubtful value, and cer-
tainly inferior to an attempt to control the inflammation and prevent pus-formation in the
deeper portion of the skin by the use of cold compresses.
While little can be done through medical skill in the actual treatment of a case of small-
pox, much can be accomplished in preventing the spread of infection, through a complete
isolation of the patient from the very outset of the attack to the close of convalescence and
tlie careful disinfection or destruction of all clothing, bedding and other ai-ticles whicli might
tran.smit the disease to others. The greatest good, however, to the greatest number, results
I'loni the prophylactic measure which, if faithfully carried out in every community, would
sooner or later annihilate small-pox. It is scarcely necessary to add that the measure referred
to is general vaccination.
(2«)
VACCIIflA.
VACCINIA.
Sy7t.onym — Coxo-pox.
A disease identical with or analagous to variola occurs ia several species of our largei
domestic animals, and is characterized by a limited eruption of pustules. These commonly
occur about the fetlocks in horses, and upon the udder and teats in the cow. Vacciuatiou,
or the inoculation of cow-pox lymph, produces a mild disease in the human spec'es, which
has been found to furnish a certairi degree of immunity from small-pox. Vacciuia may be
produced in the human subject either from lymph taken dh-ectly from the heifer (bovine
virus), or from a vaccine vesicle thus produced (humanized virus), and transmitted from one
person to another through many generations. The dried crust of the vaccine pustule may
also be used to furnish the necessary virus for vaccination.
In the performance of this simple operation it is only necessary to gently remove by
scraping the horny layer of the epidermis at a given point and apply the lymph to tlie
abi'aded surface. To effect this a clean needle may be employed and a number of crosscil
scratches made upon the surface of the skin, or what is preferable, an abrasion made no larger
than a small split pea, by means of a dull lancet or clean pen-knife blade. It is neither
necessary nor advisable to draw blood in the operation, and if care is taken a sleeping infan;
can often be vaccinated without being awakened, or without being made to cry if awake
The left arm, at the insertion of the deltoid muscle, is the site commonly selected, and from
one to three abrasions may be made. One vesicle running a typical coui-se will often afford
complete protection for many years, but three vesicles will aiford a more certain immunity.
The development and course of the vaccine vesicle is strikingly similar to that observed
in the cutaneous lesions of variola. With the exception of the mark which simple scratching
of the skin would produce, nothing peculiar is noted, as a rule, nntU the third day. A slight
redness and swelling of the wounded skin then becomes noticeable. On the following day
the epidermis is slightly elevated by an effusion of clear serum, and the vesicle thus produced
steadily increases in size from day to day, and becomes depressed in the centre. The outline
of this lesion is circular, elongated, or iiTegular, in accordance with the shape of the abrasion
previously made. The vesicle attains its greatest development upon the seventh or eighth
day. The liquid contents, owing to the peculiar fan-like mesh-work of the interior of the
vesicle, do not escape readily if the epidermis is pricked, but ooze out slowly in the form of
a mucilaginous drop. About the ninth day the clear serum appears turbid, the vesicle rap-
idly becomes pustular- in character, and considerable redness and swelling is noted in tht
immediate vicinity. Its appearance now is indeed like "a pearl upon a rose-leaf." By tht
eleventh or twelfth day the vaccine pustule has become yeUowin hue,- and in the umbilicated
portion a crust has begun to form. With the development of the areola more or less fevei
and constitutional disturbance is noted, and when several vesicles are present, the local paia
and discomfort is usually considerable. From the swollen inflammatory patch upon whicL
(27)
DISEASES OF THE SKIN.— INFLAMMATORY.
the lesions are seated, a dermatitis may extend down upon the arm or into the axilla, espe
cially if external violence lias been encountered, and occasionally a severe and even alarming
erysipelas may develop. Commonly the local and general symptoms subside with the desic-
cation of the pustule. A dark or mahogany colored crust gradually forms and falls about
the nineteenth or twentieth day, leaving a scar which is at first red, but which in time be-
comes white, depressed and foveolated.
In connection ^nth vaccination, a number of so-called vaccinal eruptions are liable to
make their appearance as a direct or indirect result of the operation. In certain cases vesico-
pustules form not only at the point of introduction of the vaccine virus, but in its immediate
vicinity, and occasonally a general eruption of similar lesions is noted. When the vaccine
vesicle is at its height, it is not unusual for erythematous macules to appear upon the arm or
other portions of the body, and even the papules of multiform erythema or an acute eiiijition
of urticaria may occur at this time.
As an incidental result of the constitutional disturbance attending the development of
the vaccine vesicle, eczema, psoriasis and other cutaneous affections may be induced whenever
a pi edisposition to their occurrence already exists. There is no ground whatever for the be-
lief entertained sometimes by the laity that these affections are transmitted by means of the
vaci ine lymph. It is true that syphilis may be and has been repeatedly transmitted through
:he use of Ij-mph mixed with blood, or a crust taken from the arai of a sjiihilitic infant, but
in the great majority of cases where an outbreak of syphilis appears shortly after vaccination
the disease is hereditary in nature, and the appearance of its cutaneous manifestations is
merely evoked by the vaccinal disease.
VARICELLA.
Synonym — Chicken-Pox.
Varicella is a well-known exanthematous affection of infancy and childhood. The name
suggests a relationship to variola, or small-pox, and there exists indeed a resemblance be-
teen the two. Until the inoculation of small-pox prevailed in Europe, varicella w as regarded
as a mild form of this disease, and its history is intimately associated with that of variola.
At the beginning of the eighteenth century Lady Wortley Montagu, the wife of the
British Ambassador at Constantinople, became acquainted with the practice of inoculating
small-pox in order to lessen the severity of the disease, and having subjected her own chil-
dren to the operation, advocated the practice with such earnestness that it soon prevailed not
only in England but throughout Europe. It was at this time that the attention of physi-
cians became directed to the study of varicella, and the question of its specific nature
assumed a vital importance in determining the value of inoculation. This practice, so start-
ling an innovation upon established custom, naturally met with opposition. Its opponents,
observing that patients after having contracted (he disease by inoculation were subsequently
attacked with what they cnnsidcn d to bo smnll-pox. claimed that inoculation possesecd no
prophylactic value. Its .-iipiioiteis. on ilic otlicr luiiid, claimed that the pustular and
VARICELLA .
vesicular eruptions sometimes occurring after small-pox were not cases of true variola, but
distinct affections, to which they gave the names varioloid and varicella. After Jenner s discovery
of vaccination the controversy respecting the identity of variola and varicella raged more
fiercely than ever. At the present day there are none in the medical profession who claim
that varioloid, or the modified form of small-pox which sometimes occurs after vaccination,
is distinct from variola. As to varicella, however, the majority of physicians, who are able
to pass judgment on the question, are agreed that it is a distinct specific disease.
Varicella is pre-eminently a disease of childhood, and is very seldom met with in adult
life. It is rarely if ever seen twice upon the same individual, although an attack of mild
small-pox or varioloid may either precede or follow the eruption. The serum contained in
the vesicles is not readily inoculable, and the eruption has no prophylactic or modifying in-
fluence over future attacks of small-pox.
Varicella occurs sporadically and in epidemic form. In large cities cases are always to
be found, and epidemics of this disease occur with far greater frequency than do thosp of
small-pox. Some claim that the disease is not contagious, and assert that its occurrence
among several children of a family is merely the result of epidemic influence. It certainly
does not appear to be as contagious as the other exanthemata. I have knowTi three out of
five young children to be affected in one household while the other two escaped. The period
of inoculation is supposed to be longer than that of small-pox or measles. During this
period the child may evince some signs of languor, but generally there is only a slight fever of a
few hours' duration preceding the eruption, and very frequently the eruption itself is the firs1>
indication that the child is not in perfect health. The eruption at the outset presents small red
macules or slightly-elevated papules upon the body, and shortly after upon the face and ex-
tremities. In a few hours a minute vesicle is noted in the centre of each i-ed macxde, its
shape varying in different cases, being either conical or hemispherical, and usually from a
pin-head to a small pea in size. The vesicles are disseminated and vary in number from a
few score to several hundred. They are quite superficial, covered by a tense layer of epi-
dermis, and surrounded usually by a naiTow zone of inflammatory redness. The contained
fluid is clear, colorless, or slightly tinged with yellow, and of an alkaline reaction, differing
in this regard from the acid serum of sudamina. The vesicles after the first day may appear
cloudy, but they never become purulent. The fever subsides on the third or fourth day,
unless kept up, as is often the case, by successive crops of vesicles. These may become
flaccid through absorption of their contents when one or two days old, or they may burst
from excessive distension or be scratched by the patient, in which case they dry in the centre-
and form yellowish or bro\vnish thin homy crusts. At this stage new papular lesions may
appear, and aborting in their course, fail to become vesicular. Some of the vesicles enlarge
by peripheral extension and form bullae, which are umbilicated when the centre of the vesicle-
has begun to dry. The crusts fail in a few days or are scratched off by the patient in his-
endeavors to alleviate the pruritus or burning of the skin, which is alwajs present in greatc;-
or less degree. Beneath is left a small, circular and slightly-depressed patch of reddened
(29)
DISEASES OF THE SKIN.— INFLAMMATORY.
skin. Scars sometimes remain tlirongh life, presenting a characteristic foiTn and a peculiar
whiteness and softness.
The diagnosis of varicella is easily made if the eruption is seen at the outset. The red
papules noticed on the child's body or neck on the first day are suggestive of mosquito bites,
and are frequently mistaken for them. The development of vesicles, however, shows that
the eruption is either chicken-pox or the vesicular stage of mild small-pox. If an epidemic of
variola is in progress the diagnosis of the case becomes a matter of considerable importance,
and an error may prove unfortunate for both patient and physician. Although variola is as
a rule a far more severe disease than varicella, it may run an extremely mild course, and does
so frequently when modified by a previoiis vaccination. In such a case the diilerential diag-
nosis is not always easy, but the chief points upon which it may be established will be seen
by reference to the foIlo^ving comparative table : —
Varicella. Mild Variola or Varioloid.
Is not inoculable as a rale. Is readily inoculable.
Attacks children recently vaccinated. Rarely occurs until years after vaccination.
Is unaffected by previous vaccination. Is modified, if not prevented by vaccination.
Vaccination will succeed after variella. It will not usually succeed after smaU-pox.
No prodromal fever of any consequence. Initial fever lasting two or three days.
Fever begins with the outbreak of the Fever abates when the eruption appears,
eruption. Eruption spreads slowly from face to ex-
Eruption spreads rapidly over the body tremities, and the vesicles develop gradu-
and vesiculation takes place on the first ally.
day.
Eruption rare in mucous membrane. Usually seen upon pharjTix.
A^esicles are superficial and have no hard Papides are deep-seated and feel "shotty."
base.
Occurs chiefly in children. Occurs chiefly in adults.
The treatment of Varicella consists simply in judicious nursing.
ERYTHEMA SIMPLEX.
This is a common and usually an insignificant affection resulting from a great variety of
causes, and rarely demanding active treatment. It consists in an eruption of bright red
patches, which gradually cliang'^ to a duller hue. They are circular or irregular in outline,
of variable size, and occur upon various portions of the body. These patches are the result
of an active or passive dilatation of the capillary vessels, and usually run an acute course.
The afl"ection may be idiopathic and result from the action of heat or cold upon the skin,
from friction, pressure or other external in-itating agents, or it may be symptomatic of some
internal disorder. It frequently occurs among infants and young children as the result of
(30)
ERYTHEMA EXFOLIATIVUM
ERYTHEMA BULLOSUM.
AKfOTrPE, t. BIERSIADT, I
ERYTHEMA a IMP LEX.
gastric or intestinal disturbance, and in adults is not infrequently due to the ingestion ol
certain drugs or unusual articles of food.
Diagnosis. Simple erj-thema is not apt to be mistaken by the physician for any other
form of skin disease, but the significance of the eruption is not always appreciated. If care-
fully studied it may serve to give a clue to some severe and impending constitutional disease.
For instance, a peculiar erj-thematous rash occurring upon the extensor surfaces of the ex-
tremities, especially about the joints, is sometimes a j^rodrome of variola.
When erythema occurs in the f onn of numerous small circular spots upon the trunk or
extremities, it has been designated as roseola. This form may be due to dental or gastro-
intestinal irritation, or it may appear as the earliest cutaneous manifestation of constitutional
syphilis. In such a case the term erji;hematous or macular syphilide is preferable to the old
expression, syjohilitic roseola.
In \dew of tlie prevailing tendency to depart from the Willanic or lesional classification
of skin diseases, the terai erythema must be regarded as a mere symptom rather than as an
independent disease, and the duty of the physician is to diagnosticate between the multitude
of causes which may give I'ise to the cutaneous congestion.
Treatment. To determine whether the congestion of the sldn is the result of an exter-
nal or an internal cause is the first stei) in the treatment of erythema. "When it results from
the pressure of a truss, a splint, or other orthopaedic apparatus {E. traumaticum) the inter-
position of canton flannel or absorbent cotton between the hard substance and the skin may
prevent the occurrence of eczema or ulceration from the pressure exerted. The erythema
I'esulting from the action of heat or cold {E. calorieum) speedily disappears with the cessa-
tion of the cause. Redness and irritation of the skin is sometimes produced by wearing new
stockings and undergarments containing aniline dyes {E. venenatum). To relieve this a
change in the character of the clothing is often necessary.
For sympathetic erj^hema, which is often persistent and sometimes associated \vith a
slight burning sensation, a removal of the cause is of the first importance. For the flushing
of the face, which is apt to occur in women at the time of the menopause, the inhalation of
amyl nitrate and the administration of mild doses of belladonna have been found useful.
Locally, a dusting powder, will commonly act as a placebo, and a lotion of lead and opium, if
called for by an annoying sensation of heat in the part affected, will prove of benefit.
Erytiiejia exfoliativum. In rare instances erythema may invade the whole surface of
the skin and cause a general desquamation. The attacks may recur at intervals, and any one
of them might be hastily mistaken for scarlet fever. The follo^ving case will serve :is an
illustration of this peculi? r form of the affection : —
Chas. O., eet. 23, Gennan.— By occupation, a porter.— The patient had a sallow com-
plexion, but was strong and apparently iu good condition. He gave the following history :
In his youth, from the age of four to fourteen, he had suffered every summer from a general
"peeling of the skin." The attack would usually confine him to his bed for five or six
weeks, and he remembers that large sheets of skin could be removed entire from his body.
(31)
DISEASES OF TEE SKIN.—INFLAMMATOR Y.
At the close of each attack, the thick skin of the soles of the feet would separate in two
portions, one from the ball of the foot and. one from the heel. His four brothers and one
sister were all healthy, as was the patient himself, between these annual attacks. From the
age of fourteen to twenty-two he was in good health, and free from his early trouble, with
the exception of a single mild attack, which occurred when about nineteen. Dui-ing the past
six months he had at least six mild attacks, in such rapid succession that the erythema would
sometimes appear upon the body before the palms had finished scaling as the result of a
former attack. When first seen by me (January 20), the patient stated that on the morning
of the previous day he had awoke to find his body and extremities reddened, as was usual at
the beginning of an attack. An examination revealed a vivid erythema upon the sides of
the trunk, the neck, arms, and thighs. The skin on the palms was dry and harsh, and ap-
parently beginning to separate. (This condition resulted from a preA'ious attack, which
occurred a few weeks before). It began to exfoliate shortly after, and jjresented the appear-
ance often seen after scarlatina. The erji:hema quickly became universal, ^dth the exception
of the face, penis, and back of hands, and was immediately followed by a desquamation of
the epidermis. On the scalp it occasioned an acute attack of pityiiasis. On January 26th
the attack was waning ; it had been severer than his recent attacks, but did not compare in
severity with those which he had as a boy. The sldn of the body appeared of a dusky red
hue. indicati'/e of venous congestion. The skin on the inner side of the thighs and gluteal
region v as qidte dark, and on close examination presented a slightly powdery surface.
Dra.virig the finger nail rapidly over it a number of times produced at first whitish, chalky
lines, v.-hich rapidly assumed a bright red color, contrasting strongly with the surrounding
livid hue. There was no evidence of urticaria, and this initation of the skin was unaccom-
panied by itching. The knees appeared whitish from the presence of thin, adherent scales,
and there was a certain amount of pityriasis on various portions of the body.
On March 2nd, patient came to me with another attack. Two days before he had felt per-
fectly well. He slept well that night, but awoke on the following morning with the redness
of the whole body, excluding head, hands and feet. The skin was hot as well as red, and he
experienced a bui-ning sensation, especially at the flexures of the joints. He felt weak
during the day, and complained of nausea, but again slept ^vell. When seen by me the
brightness of the erythema was akeady fading, and the skin appeared like that of an Indian,
or as it sometimes appears after staining with chrysophanic acid. His red flannel under-
clothing, which had lost its brightness by long use, very nearly matched the shade of the
skin. The hyperemia was intense, but of a passive character, and the body contrasted
strongly with the face, which was pale and sallow. On ]\Iarch 5th the pui-plish redness had
faded, and where the skin was naturally thin, the desquamation was beginning at numerous
points, in the form of smaU siliquose elevations of the epidermis. From these points the
desquamation proceeded centrifugaUy, leaving patches of normal skin, surrounded by an
irregular white line of exfoliating epidermis. On March 7th there were islands, not of denuded
skin, as before, but of old epidemiis. These remaining patches appeared of a dirty yellowish-
(32)
ERYTHEMA INTERTRIGO.
brown color, and were dotted by the siliquose elevations of epidermis, and small circular
spots, from wMch the epidermis had fallen. The patient was feeling perfectly well.
ERYTHEMA INTERTRIG-O.
A simple erythema is freqiiently produced by the contact and friction of two opposing
surfaces of skin. When, in such cases, heat and moisture are present to an unusual degi'ee,
a maceration of the epidermis and the production of a raw surface frequently takes place and
gives use to that condition which is usually designated by the term "intertrigo." The affec-
tion is very common in infancy, when the skin is delicate. It also occurs in adult life, espe-
cially among the corjjulent. The genital region and the gluteal furrow is its most common
site, but in very fat infants it is also observed in the folds of the neck and in the flexures of
the joints. In women with large pendulous breasts, and especially among those who are
nursing infants, it is very common. In short, it is liable to occur wherever two surfaces of
skin are in close apposition and inclined to rub against each other.
In hot weather the affection is always aggravated, but it is by no means confined to this
season of the year. It usually develops suddenly, or at least increases rapidly in severity
as soon as the parts begin to appear chafed. The natural heat and moisture of the opposing
surfaces induce congestion of the skin, and this naturally increases the amount of heat and
stimulates the persph-atory glands to excessive action. The skin now becomes deeply red-
dened, bathed in a serous discharge, which emits a very disagi-eeable odor, and in the deep-
est portion of the sldn a painful fissure is very apt to form. In infants whose urine or foecal
discharges are allowed to remain in contact with the sldn, a raw or even an ulcerated surface
may be produced, and this is more especially apt to be the case if the mine is very acid, or the
discharge from the bowels is loose and acrid in character. The affection may be slight, and
disappear spontaneously in a few days, but generally it tends to become aggi-avated, espe-
cially in the case of infants, and often persists for months or until the most careful treatment
is instituted.
Diagnosis. The intertrigo of infants is readily recognized as such, but in certain cases
where a tendency to eczema exists, the skin becomes gradually thickened and tends to remain
red and scaly after the moisture of the parts has disappeared. Just at what period the inter-
trigo may be considered as having become transformed into an eczema is not always easy to
determine. The redness and moisture are symptoms common to the two affections, but the
Infiltration of the skin is not met ^vith in piu-e intertrigo, and when present must be consid-
ered as indicative of eczema.
Treatment. The successful treatment of intertrigo is by no means as easy a matter as
one with little experience might at first imagine. The indications are- to keep the parts clean
and dry and the qjji)osing surfaces separated for a time by the interposition of some unirrita-
ting substance, be it linen, cotton, powder or salve. In infants these indications are not
always easy to fulfil. It is difficult to impress upon the mind of some mothers and nurses
(33)
DISEASES OF THE SK/y.-EYFLAMMATOBY.
the great importance of removing the napkins immediately after the passage of urine or
evacuation of the bowels. A few minutes' contact of the uriue or f ceces with the tender and
inflamed skin will often destroy the good results of the most careful treatment. When the
skin is but slightly inflamed, the parts may be occasionally washed with castile soap and
water, but when there are abmded surfaces this plan of treatment is apt to aggravate the
ti'ouble, and especially where thei-e is a tendency to eczema, water should be proscribed. A
dusting powder of the blandest character is usually of the greatest service in the treatment of
these cases, and should be freely applied to the surface. Where there is but slight moisture
lycopodium is doubtless the best application, but when a powder of an absorbent character
is needed, com starch may be used in preference to the ordinary starch powder, as it is less
gritty, or what is perhaps still better, prepared chalk or fullers' earth. "When there are raw
surfaces, a powder prepared by saturating French chalk or talc with the tincture of calen-
dula, and slowly drying the same, may be applied with excellent results, the parts being
separated by the intei-position of a piece of soft linen cloth slightly greased mth mutton
tallow to prevent its adherence.
For the intertrigo of adults a similar plan of treatment may be adopted, but in all cases
the physician must see that his directions are thoroughly carried out or success will be unat-
tainable, and even when the cure is apparently accomplished, the possibility of a relapse must
be guarded against.
ERYTHEMA MULTIFORME-
Tlie term erythema indicates a pathological congestion of the skin. When hjqiersemic
redness is the sole lesidn in any case, the affection is erythema simplex. When the conges-
tion of tlie skin is accompanied by a peculiar jilastic exudation, we have an entirely different
affection, and one to which Hebra applied the distinctive title of erythema exsudativum mul
tiforme. Although the generic term erythema, adopted by Willan in his lesional classiflca
tion, is still in use, the reader must bear in mind that erythema simplex and erythema m,ul
tiforme are not mere varieties of one cutaneous disease, but that they are quite independeni
affections, according to a classification based on etiology or pathology.
Erji;henia multifonne is an acute inflammatory affection, characterized by a marked de-
gree of supei-ficial plastic exudation. This leads to the rapid development of either paijules,
tubercles, elevated rings or diffused marginate patches. In exceptional cases, vesicles and
bullfc develop upon the sui'face of these lesions. The varying character of the eruption lias
led to the establishment of a number of clinical forms which ditl'ei- from one another in exter-
nal appearance. Chief among these may be considered three types of the affection, which
are known as Erythema j)fipul<xtum, Erj^hema hullosum, and Erythema nodosum.
ERYTHEMA PAPULATUM. This is the most common fonn of Erythema multiforme
and occurs chiefly on the backs of the hands and foreamis. In some cases it appears on the feet
and legs as well. The lower extremities are rarely affected alone. In E. tuberculatum the
(.34)
^
m
'"^i
s ^
<^
'^
1^1
^
^
■ .^^^•■'■•■■^^^^^^^^^^^^^^^^^^"
ERYTHEMA MULTIFORME.
ER YTUEMA M UL T I FOE ME.
papules are simply larger and firmer. They present at times a whitish summit and appear
like buUfe containing gelatinous contents. In a case which I recently saw, the tubercles on
the backs of the fingers were dark and purpuric in character. In E. annulatum a large flat
papule or disk of exudation presents a depressed central areti, and in rare instances, one or
more outer circles form, and by exhibiting a variation in color give rise to the name E.
iris. E. marginatum is applied to the eruption when it appears in the foi-m of diffused
patches with an abrupt and elevated border which is usually scalloped from the coalition of
smaller circular patches.
The following case will illustrate the features of the annular form of erythema : — W. R..,
set. 34, American. — By occupation, a pilot. — This patient was sent by Dr. Robert Abbe to a
meeting of the New York Dermatological Society, and afterward kindly placed under my
observation. He was a large and powerful man, apparently in perfect health. A searching
examination made by Dr. Abbe failed to reveal any history or evidence of syphilis. He had
never had any eruption elsewhere upon the skin, and with the exception of a slight attack of
rheumatism, had never been iU. His tongue was clean, his appetite good, his bowels slightly
constipated, and his urine clear. He stated that, six weeks previously, a small, itchy red
spot appeared in the centre of his left palm, and gradually increased in size. A few days
later two similar spots appeared in right palm. About six months before this, the patient
had suffered from a similar, though milder attack. There were, at that time, two or three
circular, non-elevated patches in each palm, which itched exceedingly, and disappeared in
about a month without treatment. No scaling followed. Upon examination of the palms
during the second attack, the centre of each was found to be the seat of a nearly circular,
purplish-red ring. The circle in the left palm (see illustration in first edition), pre-
sented an irregular border, and appeared as though one or two small rings had coalesced
with the central circle by centrifugal extension. On the right palm were three small lesions,
in addition to the central circle, two being near the latter, and one on the long linger, near
its base. The e small lesions were just beginning to grow annular by a fading of the color
in the centre. The central circles were of hali dollar size, and not at all elevated, although
Dr. Abbe assures me that they were so at the outset. Their most striking feature consisted
in a double border, the inner one being of a purplish-red color, and evidently indicating th(
height of the exudative process, the outer one appearing whitish, like the epidermis raised
by a blister. The lesions were not very striking in appearance, especially the incipient ones.
But the purple band of the central circles showed very plainly when the lingers were forcibly
extended, so as to blanch the surrounding tissue, or when the palm was rubbed briskly for a
few seconds with the corner of a dampened towel. The eruption was accompanied by a severe
and annoying itching, which kept the patient rubbing or picking at the palms, but the epi-
dermis was not at all excoriated.
The treatment adopted at first, in this case, was purely expectant, but as the eruption
showed no tendency to disappear of its own accord, as it had done six months before, the
patient was ordered nightly frictions with green soap, to be followed by the uiuufjlon of
(:35)
DISFASFS OF THE SKIN.— INFLAMMATORY.
mercurial oiaiiiient. This appeared to have no effect, and on January 6, two weeks after the
photognii^h was taken, the rings were increasing in size, and very itchy, especially after wash-
ing the hands. Rochelle salts internally and chrysophanic acid ointment locally were ordered,
and the eruption disappeared after a duration of ten weeks.
In the beginning, the eruption of Erythema multiforme, whether papular, annular or
marginate, is seated upon a slightly swollen and reddened base. "Within twenty-four hours
the encircling hypereemia subsides, and leaves the eruption contrasting strongly with the
normal skin. The color changes gradually from a bright red to a dull, livid or purplish hue,
and the affection runs its course in from one to six weeks, according to the intensity of the
exudative process. An average case will last from two to three weeks. Frequently the
lesions develop successively, aiad the attack is thereby prolonged. Recurrent attacks at cer-
tain seasons of the year are not tmcommon. The outbreak of the eruption is often associated
with malaise and slight fever, and according to my experience, the eruption is usually quite
annojdng on account of the burning sensation or pruritus, which is nearly always present.
Most writers, however, speak of the subjective symptoms as being insignificant.
The causes of erythema papulatum are rarely apparent. It is frequently met witli in the
spripg and autumn, and the sudden changes of temperature so common in this climate seem
to me to be an etiological factor of importance. In dispensary practice I have had occasion
to note that immigrants are a class peculiarly liable to be affected. In many cases a lowered
tone of the system is evident, but the disease does not seem, like urticaria, to be attributable
to dietetic en-ors. It is generally met with in youth and middle age, and neither sex is ex-
empt.
DiACrifosis. Erythema papulatum occurring in a well marked and typical form is easily
recognized by any one at all familiar mth the clinical appearance of the affection. In many
cases, however, it might be readily compounded with urticaria, eczema or syphilis. From
urticaria, to which it is closely allied in its pathological nature, it may be distinguished by
the persistence of its lesions and by the subjective sensation, which is one of burning rather
than itching. The papules or patches are never white like the wheals of urticaria, nor do
they ever appear and vanish as suddenly. "When eczema occurs in small imperfectly de-
veloped patches upon the backs of the hands, and on the forearms, a difficulty in diagnosis
might arise at the outset. But the speedy appearance of a tendency to moisture, or the in-
evitable formation of scales would greatly lessen the resemblance, inasmuch as the lesions of
papular erythema never present an exuding surface, nor become scaly. They always possess
nioreover an abrupt margin which is very rarely met with even in small jjatches of eczama.
Tkkatmext. The treatment of the affection may be expectant or consist in good nurs-
iag. Warm baths are beneficial. A teacupful of carbonate of sodiiun may be added to the
Mater ^^hen the eruption is extensive and accompanied by pruritus. A linen cloth saturated
A-ith a lead lotion may be applied to the affected skin at the outset, when the inflammatory
symptoms are very acute. Later a dusting powder may be prescribed with a view to divert-
(36)
Eli YTUEMA 21 UL Tl FORME.
ing the patient's mind, or if the burning sensation is very annoying, the following ointment
may be gently applied vnfh. a certain amount of benefit :
'^ Salicylic Acid, ... 2 parts.
Camphor, . . . . 2 "
Ointment of Eose water, . to 50 "
M.
ERYTHEMA BULLOSUM. Hydroa, a term first employed by Bazin, has gradually
come into use during the past twenty years. It is generally applied to certain cases
of vesicular or vesiculo- bullous eruption occurring upon an erythematous base and pos-
sessing clinical features which serve to distinguish them from herpes and from pemphi-
gus, with which afi'ections they were formerly confounded. The disease is not a common
one, and while the cases met with present salient features which mark their identity, they
vary in their clinical aspect to such an extent that a concise definition cannot be given which
will include all forms of the affection. For the most part they present the features of multi-
form erythema with the vesicular or bullous development super-added. The term erythema
bullosum is therefore preferable to the term Hydroa, which does not suggest the fact that
the affection is but a phase of erythema multiforme. The leading characteristics of erythema
bullosum are its symmetrical distribution, its peculiar locality, its tendency to recur at longer
or shorter intervals, and the constitutional derangement which usually accompanies the erup
tion. It begins, as a rule, by the sudden development of erythematous papules or patches,
upon the central portion of which a single vesicle or group of vesicles is rapidly f onned. These
are usually of large size and hemispherical. They contain at first clear seram, which in a few
days becomes cloudy and gives to the patches a whitish or even a yellowish aspect. There
are generally some isolated vesicles or bullae, and these do not always spring from an erjrthe-
matous base. They may attain the size of pemphigus bullae, and become surrounded as they
mature, by a narrow zone of infiammation. The groups of vesicles tend to become depressed
in the centre, and sometimes an advancing vesicular margin is noted. A tendency to succes-
sive crops of vesicles is common, and when the eruption is subsiding at one point, a relapse
may take place upon some other portion of the body.
The serous contents of the vesicles and bullae tend to become absorbed and leave merely
a desquamating epidermis, but when the lesions are ruptured by scratching or other external
violence, a yellowish crust or a dark scab may form. The subjective symptoms, in a mild
case, consist chiefly in a burning sensation, but in many cases, and especially in those which
run a more chronic course, the itching may be intense. There is generally a mai-ked impair-
ment of the general health preceding the attack, and while the eruption is present, the patient
is usually wholly unfitted for his customary duties. There occur now and then rheumatic com-
plications, and effusion into the knee joint has been reported. The disease commonly runs an
acute course, the successive crops of vesicles disappearing in a few weeks or months, but it
may persist for years. It is non-contagious, and though in many instances a severe affection,
it is rarely, if ever, fatal.
(37^
VISEASES OF THE SKTX.— INFLAMMATORY.
The favorite seat of erythema bullosum is upon the extensor surface of the forearms and
hands, the face and ears, the genitals, knees and feet. In many cases the oral cavity is like-
•wise affected, the uviila and soft palate being frequently the seat of vesicles, or presenting an
inflamed or eroded appearance. The affection is apt to attack young persons, and appears to
be most common in the early mnter and early summer. Some may have a number of attacks
during the year, and cases have been reported where an annual attack has occurred since
childhood. The causes of the affection are obscure, but it is evident that the eruption is
due to derangement of nerve-centres, and not dependent upon any blood changes.
The diagnosis is not difficult, but as there are no sharp boimdary lines between herpes,
erythema bullosum, and pemphigus, cases often occur which illustrate the relationship of the
three affections named, and a question might arise as to the most appropriate term for a
given case. The main features of the three affections may be contrasted as follows : —
Lesion.
Location.
Course.
Treatme.
Hekpes.
Vesicles in
groups.
Face and genitals
only.
Acute, lasting but
a few days.
None required.
Erythema bullosum.
Large vesicles or bullse
isolated or grouped.
Face, forearms, scrotum,
knees and feet. Rarely
general.
Acute or chronic, lasting
a few weeks or longer.
Treatment may hasten
the cure.
Pemphigus.
Bullse, always iso-
lated.
All portions ol
the body.
Chronic, lasting
for years.
Is rarely cui-ed,
and often fatal.
The chief aim of treatment in a case of erythema bullosum should be to restore to the
patient his natui-al degree of health of mind and body, talving little account in most cases ol
the eruption upon the skin. The nervine tonics, such as arsenic, quinine, and cod-liver oil,
are highly recommended, and ^^'ith these, and the beneficial effects of a complete cessation
from work and wony, with perhaps a change of scene when it is practicable, a speedy cure
may be expected. When the patches aie in a highly inflammatory condition, the common
lead and opium wash is of sei-vice, and when itching is a prominent symptom, the parts may
be rubbed with camphoiuted oil.
ERYTHEMA NODOSUM. This is described by some as distinct from erythem;. multi-
forme, but its nature is thj same however different may be its appeai-ance. Although it
is almo'it always met with alone, it may co-exist with the papular or marginate forms. It
is usually met with upon the extensor aspect of the legs and arms, and is characterized by
' liH ai)peai'ance of one or more painful swellings, varying in size from an almond to a small egg.
These appear usual!}' in connection with marked general malaise, and more or less fever,
develop rapidly and run a course of from two to three weeks. Sometimes a succession of
(38)
1
URTICARIA.
ARTOTrPE, E. BIERST»DT
URTICAIIIA.
lesions will prolong the disease. The nodose swellings reach their height in two or three
days, and at this time present a peculiar bluish red appearance, somewhat resembling a
recent contusion.
The border is never abrupt and the color gi-adually shades off into tlie surrounding skin.
The subjective sensation is of a burning pain, the affected skin is exquisitely tender, and
when the lesions are numerous upon the shins the patient becomes scarcely able to walk.
The tumors may remain in this condition i'or two or three days, when the tension of the
skin lessens, the swelling subsides slightly, the color becomes duller and sometimes passes
through the variegeted changes which are noticed after a bruise. Children and young women
are most apt to suffer fi'om the affection, and more especially those who are weakly and iU
nourished.
Diagnosis. WTien the affection occurs, as it does in the vast majority of cases, over the
shins, it might be mistaken at first sight for a number of contusions. But the absence of
any history of external violence, together with the marked constitutional disturbance, will
serve to exclude such :i diagnosis. Abscesses, boUs and the gummy tumors of sj^phOis bear a
slight resemblance to the lesions of erythema nodosum, but the latter are too highly colored
for incipient abscesses, too large as a rule for furuncles, and too acute in theu- course foi
gummy tumors. WTien the lesions occur, as they may do, upon the face or body, the diag-
nosis is more difficult and can only be made after a most careful study of the case.
Teeatment. As the disease runs its course and terminates spontaneously if left to itself^
our chief aim in treatment is to ease the suffering of the patient, which is usually considera-
ble. It is probable also that judicious treatment will shorten its natural course. Rest in
bed, ^^'ith hot applications to the painful tumors, is of the first importance. Aconite may be
administered in small doses at the outset and followed by iron and mineral acids. Locally,
Piffard recommends the application of hamamelis and arnica, which may be employed to
advantage in connection with the hot compresses. Finally, when the tenderness of the
lesions upon the legs has subsided, the finn pressure of a smoothly applied flannel bandage
w'ill hasten a cure.
. URTICAIIIA.
{Synonym — Nettle Hash, Hives.)
Urticaria is an affection of the skin, in which certain peculiar lesions called "wheals"
appear suddenly 'uith or without apparent cause, and after a brief dvu-ation of a few hours
disappear almost as si.ddenly as they came. A single outbreak of these wheals may consti-
tute the whole of the uttack. but generally they appear as successive crops, and thus the affec-
tion assumes a chronic form. The wheals are solid inflammatory elevations of the skin of a
perfectly white or pinkish hue, with an abrupt margin and a bright red hj^per^mic halo.
They are commonly circular or oval in shape and vary greatly in size. In a mild case they
are no larger than the tip of the finger, but in a severe acute outbreak they may occur in
(39)
DISEASES OF THE SKIN.-iyFLA2IMAT0RT.
piitches 'A iiTegiilar fonn, and cover portions of the body as large as the palm of the hand.
In certain cases the whole trunk wU be covered either by the wheals themselves or by the
active h\-perjBmia which surrounds them. Occasionally the wheals arp linear in fonn, espe-
cially when induced by the pressure or friction of the clothing. Though commonly raised no
more than an eighth of an inch above the level of the skin, in rare instances they fonn
tumors ad large as an English walnut (giant urticaria).
Acccmpanying the lesions there is always a bui-ning or stinging sensation, which is
extremel r annoying, and frequently there is such an intense pruritus that fierce scratching
and exec nation of the skin is inevitable. During an attack the skin over the greater portion
of the body is abnormally irritable, and the scratching only serves to increase the number of
wheah. The affection occurs at aU ages, but the acute form is more common in childhood.
The eruption may exist alone or in connection va(h. some other disease of the skin.
Etiology. There is no affection of the skin \vhich may result from so many distinct
causes as urticaria, and as success in its treatment depends largely upon the discovery of the
cause, an acquaintance with its various etiological factors is of the highest importance. The
eruption, or at least the peculiar u'ritability of the .skin which precedes and favors the erup-
tion is always the result of reflex nervous irritation, and the exciting cause may act either
within or without the body.
The external causes of the eruption may be of a vegetable, animal, mechanical or
meteorological nature. The contact of the skin with certain species of Urtica or stinging
nettle is the most evident of all the external causes of urticaria or nettle-rash, and the one
which has given to the disease both its scientific and its poptilar name. The stinging power
which the nettle exerts is supposed to reside in minute tubular hairs or prickles, which transmit
a venomous fluid when pressed. It is well known that the bites of mosqtiitos, bedbugs, lice,
and ileas often evoke urticarial wheals, not only at the seat of attack but upon other portions
of the body. In the case of the two latter pests the exciting cause of the eruption is not
infrequently overlooked. The eruption may result also from contact with the slimy secretion
of the jelly-fish, and with certain hairy caterpillars of the genus Bombyx. Upon a healthy skin
a linear wheal or welt can readily be prodticed by giving the skin a sharp cut with a switch.
Upon the skin of certain susceptible persons a somewhat similar lesion may be produced by
the pressure or friction of clothing or mechanical imtation of any sort. Letters traced upon
the skin ^\•ith the finger-nail, or any pointed instrument, will appear in white relief ttpon a
pink background in the course of a minute or two ( U. factitia). The application of leeches,
and the puncture of echino-coccus cysts have repeatedly been followed by the development of
urticaria. The disease sometimes coexists or alternates with asthma, in which case it is very
apt to be induced by exposure to cold air.
The internal causes of urticaria are even more numerous than the external, although less
susceptible of demonstration. They may be classified as dietary, medicinal, emotional or
morbid in character, and the resulting eruption must be regarded as a purely symptomatic
one. Urticaria from the use of certain articles of food usually appears in an acute form, with
or without fever. In some instances the eruption appears with a marvellous suddenness, even
(40)
URTICARIA PIGMENTOSA.
lOtTPt, E. BIEKSTAOT, N. r.
JJRTICAlilA.
before the offending substance has been fairly swaDowed, and from this it would seem pit)ba-
ble that the peculiar irritation of the nei-ves of taste is reflected immediately to the skin, and
that the eruption is not due to the absorption of the substance and its circulation through the
blood. The articles of food which have been observed to produce this singular effect upon
the sldn in the case of certain individuals are eaten by others with perfect impunity. The
list of such articles is an extensive one and comprises fish, clams, oysters, lobsters, crabs,
pork, eggs, honey, mushrooms, cucumbers, berries, fruit, etc. Various drugs, when taken
internally, are liable to provoke an exanthematous eruption (Dermatitis medicamentosa)
which is ofteji of an urticarial character. Quinine, cinchonidia, salicylic acid, belladonna,
valerian, copaiba, chloral, santonine and hyoscyatnus are among those whose action must be
watched most carefully with a view to their incidental effects upon the skin. Urticai'ia from
mental excitement and from some obscure affection is possible, and this fact must be some-
times considered in our treatment of a case.
Diagnosis. If a typical case of urticaria is seen when the eruption is at its height a
difficulty in diagnosis could hardly occur, as the wheal is a lesion which is peculiar to urti-
caria and met with in no other affection of the skin. But these lesions are so evanescent in
character, both in the acute and chronic forms of the disease, that, like the toothache which
so of^en disappears at the dentist's threshold, they are frequently invisible when the physi-
cian is called upon to examine the patient. In chronic urticaria the diagnosis must often be
m'jde when no wheals are present, but the characteristic history which the patient gives of
lesions occurring suddenly, itching or burning severely and disappearing speedUy will usually
lead to a correct appreciation of the nature of the eruption. Moreover, in chronic m-ticaria
the excoriations of the skin which are left after the primary lesions have gone will serve
often as a valuable aid in diagnosis. Since patients subject to m-ticaria present a character-
istic irritability of the skia, the following test maybe resorted to in aU cases where a prui-itic
condition of the skin is complained of without apparent lesions. If the finger-nail be quickly
drawn ortr the skin in parallel or crossed lines, or the skin lightly scratched with any blimt
pointed Jistrument, a hyperffimic surface will be instantly produced, and in a few seconds a
number of ridges of a pinkish or whitish hue wU appear. Occasionally patients are met
with of a highlv nervous temperament upon whose skin this factitious urticaria can be de-
veloped at will. ySee plate.)
Erythema multiforme, an affection closely allied to urticaria, may be distinguished by
the persistence of the lesions. Giant urticaria might be mistaken for erythema nodosum in
the rare cases in which they occur, but the course of the lesion mil here again serve as a
guide. Upon the face urticarial lesions often produce redness and swelling of the eyelids
simulating erysipelas, but the affection is never ushered in by a chiU nor accompanied with a
notably elevated temperature.
Treatment. It has been Avisely remarked that the difficulty in curing a disease i''
always in direct proportion to the number of remedies which have been recommended in it>
treatment. Ui-ticaria is no exception to this rule. Its frequent obstinacy is attested by th^
(41)
DISEASES OF THE SKI .\ .-1JSFLA21MATVRT.
experience of nearly every physician, and yet there is scarcely an affection of the skin foi
which so many drugs have been vaunted, tested and discarded .
Of the treatment of acute urticaria little need be said. The cause is usually ephemeral
and a purely expectant plan of treatment, though not to be recommended, will be followed in
most cases by a speedy return to health. Since the eruption is so frequently due to the in-
gestion of iiTitating substances, the main indication for treatment is to evacuate the
alimentary canal. The emetic which is so commonly prescribed, though rarely until after
the offending substance has passed through the stomach, too often fails to remove the source
of trouble, and only relieves the eruption by its temporary effect upon the cutaneous circu-
lation. In urticaria db ingestis, particularly in children, a dose of rhubarb and magnesia, or
of castor oil, Avill usually do far more good than an emetic, since the irritation which pro-
vokes the eruption is more frequently intestinal than gastric. In acute urticaria from other
causes treatment consists almost whoUy in relieving the distressing pruritus during the con-
tinuance of the attack. For this purpose one of a great variety of soothing applications may
be selected. In my experience alcohol has proved to be the most convenient and beneficial
lotion, and to obtain the best results it should be merely dabbed upon the skin with a sponge
or soft cloth and allowed to evaporate, the patient being cautioned not to rub the affected
parts. Cologne water, sweet spirit of nitre, vinegar and dilute nitric acid have also been
highly recommended. The dependence of urticarial wheals upon contraction of the cutaneous
muscular fibres would lead one to regard the local use of chloroform as of probable value,
and this has been verified by experience. Either of the following applications may be
employed : —
9. Chloroform ... 10 parts. '^. Chloroform .... 10 parts.
Cold cream, to . . 50 " Oil of sweet almonds to . 50 "
M. M.
The use of baths in acute urticaria may tend to excite the skin and thus do harm in
some cases, while soothing the skin in other cases, especially if carbonate of soda with boiled
starch, bran or oatmeal be added to the water. The eruption is said to have disappeared
immediately after plunging the feet and legs in hot mustard water.
The successful treatment of chronic urticaria must depend upon a knowledge of its
etiology, and a diligent study of the varying causes of the disease will prove far more condu-
cive to its cure than any amount of blind experimentation mth remedies.
A very important class of remedies are those which tend to eliminate from the blood the
imperfectly oxidized products of digestion and the impurities resulting from tissue metamor-
phosis. Of these the various alkaline diuretics and saline purgatives \\nl\ be found beneficial
through their tendency to promote the excretory functions of the kidneys and bowels, and
thereby to lessen cutaneous congestion.
Since indigestion is such a common cause of urticaria, anotlier important class of reme-
dies are those which allay irritation of the gastro-intestinal tract Of these rhubarb and bis
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DERMA TIT IS.
miitli have been justly praised. The admmisti-ation of sulphurous acid in teaspoonful doses
well diluted is not particularly palatable, but it will often produce a remarkable effect upon
the eruption, probably by virtue of its action in checking the fermentative changes in the
ingested food.
A third class of remedies are such as act mainly upon the nervous system and tend to
lessen reflex irritability. This class comprises a number of drugs, most of which have a
direct influence upon the cutaneous circulation, and many of which have been known to
produce an urticarial eruption when administered in other diseases. Quinine, cinchonidia
and cinchona bark e. g. are reported to have both caused and cured urticaria, and in many
cases of intermittent fever it may be difficult to decide whether the drug or the malaria is the
cause of the eraption. "When the disease occurs in malarial subjects the drug may be ex-
pected to do good in checking the eruption if it has not already been given in large doses.
Bromide of potassium or sodium given in sufficiently large doses to produce symptoms
of bromism will often have a speedy and marked effect upon troublesome and persistent cases
or urticaria, especially such as owe their origin to neurasthenia rather than to indigestion.
Belladonna and atropia, salicylate of sodium, arsenic, strychina, aconite, balsam of
copaiba, ergot and a host of other remedies have been highly praised by some while they have
signally failed to manifest their alleged therapeutic power in other hands. The apparent
value of many remedies has undoubtedly been based partly upon careless observation and
partly upon the fact that the eruption sometimes disappears suddenly for a short time without
any treatment whatever.
DERMATITIS.
Inflammation is the essential element of each disease of the class now under consideration,
but the limitation of the inflammatory process to certain anatomical elements of the skin pro-
duces a variety of lesions and a peculiar clinical aspect in every case. When simple inflamma-
tion attacks the skin as the result of definite causes, it has been found convenient to apply the
term dennatitis, with certain qualifying adjectives which serve to denote the nature of the
cause. The usual symptoms are merely redness, heat, pain and swelling, but in some cases
the lesions common to other inflammatory affections are met with. The grade of inflamma-
tion varies in accordance with the nature of the exciting agent, and the peculiar susceptibil-
ity of the skin. In many cases we may have nothing more than a simple, or no >i exudative,
erythema, while in other cases the inflammatory process leads to an eruption of vesicles,
pustules or blebs, and occasionally the occurrence of gangrene.
DERMATITIS TRAUMATICA. This term includes the result of constant pressure and
severe friction, bruises and wounds of various sorts, the stings of iiisects, and the excoria-
tions produced by the free use of the nails to allay itching. The cause of the trouble may
be generally determined by careful observation of the affected skin in connection with the
history which the patient gives. The necessary treatment naturally involves an attempted
removal of the cause, and will be suggested by the nature of the case.
(43)
DISEASES or TEE SKm^INFLAMMATORT.
np^BMlTTTTS CALOKIOA-This embraces various forms of cutaneous inaammatiou
resru«™e -ou of ^ e^rcrue degree of heat an. cold. It inCudes sunburn. ordt-
°"'^w^:tn\rrr°rc-t:ri^^.-^^^^^^
::e^:Ler'T:^;ri.elnOaence''o,tbenatu«.pi^^^^^^^^^^^
a h.,1 ), the white portions of the skin become ni„uij
sur.- mding skiu remaius unaffected, or simply becomes of a a"^"^"^ ''"^f ^cted from the
^. sunburn is especially apt to occur^ben Ways ^^^J^J^^l ^^^^^ ,„„ ,
surf=«e of a body of water, and children at *« S''^^''"'' "«' ^^^^„,yj„, ,eveml sue-
long time in sbaUow water with both arms and legs bare, often suffei severely to
'^'I'^e'tr.meut of sunburn ordinarily demands nothing more than simple — n "f ^
'-;t:Xrsr(i:£)C":reaiance and -.;.—--
tempel^ture of the agent which ha= produced them the 4u^» : ^11 e been
capillary vessels, and a consequent passive conges on. ^^^^''^Zlll ^^^^o^^^ dull in
bright tint, and associated ^^-itll more or less swelling and pam gradually
hue, and is f oUowed in the course of a week or two by desquamation. In a burn of the sec
ond de^ee which may result from a contact with boiling water or heated metal tt^e ^JP"
iri:so'intenseinclaracterthatane.udatW.^^^^^^^^^^
usuaUy rounded and tense, and appear of a yellowish hue. In some c^^s ^^^^^^
homy layer of the epidermis which is elevated, and the prick of a pin ^^^^-^^f^J ^^J
exit \o the confined serum and cause a collapse of the bleb In other ^^^^^f^^^l^^^^
tion of the epidennis is mised, and a prick or incision will only evacuate a P^^^ "/l ^ s
senim and .ill leave the roof of the bleb still somewhat elevated by a pulpy exuding mas
Z^i^ frequently a slight amount of hemorrhage, especially ii the ^^^^f^^
violently niptured or rubbed o., and a thin, dark cru^fon^^^^^^^
of the epidermis gradually takes place. In a burn of the third degree, the y
DISEASES OF TEE SKIN.— INFLAMMATORY.
and sub-cutaneous tissue is destroyed, and sloughs of varying size are produced. These be-
come loosened by a suppurative process in four or five days, are gradiially cast off if not
intentionally removed, and leave an ulceration which in time is followed by a contractile
cicatrix. The scar which follows an extensive bum is always more or less puckered, and
presents ridges which often radiate from the point where the destruction of tissue was most
marked. When occurring upon the face, neck or neighborhood of joints, a considerable
deformity is often i^roduced by the gradual contraction of the cicatricial tissue.
The diagnosis of a bum is easily made, as the patient can easily furnish information as
to the active cause. The lesions of the skin which result from the action of intense cold, are
essentially the same as those resulting from a high degree of heat. A scald or bum resulting
from the action of hot liquids differs from a burn produced by the contact of iiame or hot
metal, inasmuch as the hair upon the surface of the skin is immediately destroyed in the
latter case, but not in the former.
The treatment of burns varies according to the nature of the case ; and the selection of a
local application may be made from an infinite number which have been highly recommended.
For a bum of the first degi'ee, or even one more severe, no better application can be made at
the outset than a saturated solution of bicarbonate of soda. This being usually on hand in
every household, can be applied immediately by means of moistened cloths, and in most
cases it affords immediate relief from the pain. Later a dusting powder of corn starch, or
precipitated oxide of zinc may be prescribed, and when the skin begins to peel an emollient
ointment is advisable.
In burns resulting in the formation of bullae, it is important to protect the part from
external '.oolence. The serum confined in tense blebs may be evacuated by a needle prick or
incision of the elevated epidermis, but care should be taken that this is not torn or rubbed
off, ni a portion of it may become reunited to the skin beneath, and all of it serves as the best
possible protection to the raw surface. The bullae, after careful evacuation of their contents,
may be dressed with the familiar combination of limewater and linseed oil, or sprinkled over
vrith bismuth powder.
When sloughs have formed, the best plan of treatment is to keep the parts covered -vvith
ot enveloped in hot compresses sprinlded with some disinfectant fluid. Such dressings, re-
D.owed every two hours, will lessen the inflammation, hasten the separation of the sloughs
and promote the healing of the resulting ulcers.
Frost-bite (Congelatio), or the cutaneous inflammation caused by exposure to a very low
temperature, is characterized by symptoms quite similar to those already described under the
head of burns. According to the intensity of the cold and duration of the exposure, we may
have a varying degree of inflammation, varying from slight redness and swelling (Congelatio
erythematosa), to the formation of large blebs (c. bullosa), and subsequent sloughing of the
skin (C. gangrenosa). A frost-bitten portion of skin is at first white and stiff, but this con-
dition quickly gives place to a dull red or livid hue when the patient enters a warm atmos-
phere.
DISEASES OF TEE SKIN.— INFLAMMATORY.
A frost-bite 3f the first degree frequently affects the ears, nose, cheeks and hands, and
although the redness and swelling usually disappears entii'ely in a few weeks, it is not mi-
common for the parts to remain in a chronic erythematous condition until warm weather
returns, and in some cases this passive hj^persemia persists for years.
The second degree of dennatitis fi'om cold is most frequently noted upon the fingers,
where large tense bullae form, as seen in the illustration. {See plate.) This condition leads
to superficial ulceration, and frequently to a temporary loss of the nails. If the fluids con-
tained in the tissues have been completely frozen, a restoration of the circulation in the part
is not to be hoped for, and one or more phalanges of the fingers or toes are usually lost by
the subsequent sloughing which inevitably takes place.
The very first step to be taken in the treatment of a severe case of frost-bite, provided
the patient is ■seen in time, is to prevent a too rai)id retiirn of the circulation in the affected
part. To this end the patient should be kept in a cool or even cold room, and compresses
dipped in cold water applied freely. When the hands and feet are the parts affected, an
elevation of the limbs will tend to lessen the intense reaction, and thereby, to a certain ex-
tent, control the consequent dermatitis. The buIljB which fonn should be pricked or freely
incised, to allow an escape of their serous contents, but the epidermis, as in the case of burns,
should be retained as a natural covering for the inflamed tissue. Should gangrene set in,
surgical measures should be promptly resorted to. with a view to the prevention of septic
poisoning.
Chilblain (Pernio), is a chronic circumscribed inliainination of the skin, which occurs
chiefly in the ^^inter, and is prone to affect children and adults of low vitality and poor
circulation. Its most common site is upon the toes, although other exposed parts may be
affected. The skin is swoUen, of a bluish red hue, and a disagreeable burning or itching is
commonly present. In the treatment of this common and annoying affection, careful atten-
tion must be paid to the general health of the patient. The feet must be warmly clad, and
exposure to cold and dampness avoided as far as possible. Of external applications a
countless number have been recommended and employed Avith a varying degree of success.
In most cases a stimulating application, such as spirit of turpentine or balsam of Peru, may
be rubbed gently upon the affected skin at night with benefit, or flexible coUodion or solution
of gutta percha may be kept constantly applied.
When superficial ulceration has attacked the sm-face of the chUblain, the following oint-
ment \vill be found of value :
]^ Iodoform, 2 parts.
Balsam of Peru, . . . . 3 "
Petrolatum, . to . . . 20 "
M.
DERMATITIS VENENATA. Under this head are classed certain inflammatory condi-
tions of the skin which result from the peculiar irritating action of various external agents.
(46)
DERMATITIS.
These include tlie escharotics, such as nitric acid, potassafusa, and the various caustic applica-
tions ; the rubefacients, such as mustard, castor oil and cantharides, and a number of poisonous
plants. When applied to the skin, either intentionally or accidentally, these exert an inflam-
mation characterized b}^ simple redness or the formation of vesicles or pustules, and usuallv
of such a peculiar appearance that the nature of the exciting cause can be di\ined.
One of the most interesting forms of dermatitis venenata is that produced by the contact
of the skin with certain species of sumach, and especially the Rhus toxicodendron, or poison
ivy, and the Rhus venenata, or dogwood. The eruption generally appears upon the hands
at first, as these are most likely to come in contact with the plant, but usually in a few hours
the forearms, face and frequently the genitals become similarly affected. The first symi:>tom
of the eruption which may not be noted until several hours after the exposure is a smart-
ing or tingling sensation in the skin. Erj^hematous patches now develop, upon the sur-
face of which numerous small and thickly crowded vesicles soon appear. The skin often be-
comes swollen and painful, and in addition to the local discomfort a slight febrile condition
may be observed. The eruption runs a course similar to that of an acute eczema, and in from
five to ten days the vesicles have usually disappeared and given jjlace to a reddened and des-
quamating condition of tlie affected jiarts. A fresh outbreak of the eruption may now take
place, even without renewed exposure, and in this way the eruption is sometimes prolonged
for many weeks. Some patients who have suffered severely from ivy poisoning ^^dll com^^lain
of an eczematous eruption, which seems to occur every year upon the face and hands at about
the time of the year when they were first affected.
There is a marked difference in the susceptibility of persons to this i)eculiar eruption.
While some can handle the i^lant with impunity, and even rub the leaves or juice exuding from
the broken stems upon their skin without exciting the slightest dermatitis, there are others
who become affected in a marked degree by the i^oisonous exhalation which pervades the im-
mediate vicinity of the fresh plant. I have a patient who assures me that he cannot drive
through v.-oods where the poison siimach abounds without subsequently suffering from the
charactei'istic dermatitis, and that merely passing to the leeward of a field where farmers were
burning brush has repeatedly been sufficient to evoke the eruption. The poisonous influence
is frequently carried in gloves and other articles of clothing, and in knives which have been
employed in cutting the leaves or branches, and thereby certain susceptible individuals may
be unexpectedlj' affected. Physicians have been known to handle the rhus without injury to
themselves but with detriment to susceptible patients whose skins they have shortly after-
wards touched and j)oisoned.
Diagnosis. The eruption resulting from ivy poisoning, when seen at its height, can
only wdth difficulty, if at all, be distinguished from an outbreali of acute eczema. But the
characteristic localization of the eruption upon the hands, face and genital region will usually
excite suspicion as to its nature, and the history which the patient often gives of having been
in the woods just before the outbreak of the eruption will serve to verify the diagnosis.
Treatment. There are few affections of the skin for which a greater number and variety
(47)
DISEASES OF THE SKIN.— INFLAMMATORY.
of remedies have been recommended than for the dermatitis of rhus poisoning. A mere list
of them woald require several pages, and though many of them have been vaunted as infal-
lible, it is probable that most of them have been tried in vain by other and less enthusiastic
physicians. It is extremely doubtful whether there is any specific remedy which, given inter-
nally or applied locally, will cut short the attack, and yet much may be done to relieve the
suffering of the patient. Enforced rest, light diet and cooling drinks wiU prove of benefit in
every severe case, while smaU doses of gelseminum or grindelia robusta will certainly do no
harm. Of local remedies the one which I have found to be as valuable as any of the number
which I have tried, is lime water. If this is applied frequently by means of linen cloths dur-
ing the height of the eruption, a soothing effect may be expected. The liquor sods chloratse
may also be used to advantage, either pure or diluted, with rain water. When the acute
infiammation has subsided a soothing ointment will protect the tender skin and prove less
troublesome in its application than the lotion.
ECZEMA.
Synonyms — Salt rheum. Moist tetter.
Eczema is the most common affection of the skin which the physician is called upon to
treat. According to the various statistics of private and dispensary practice, it includes
about one-third of all the cases. It occurs at all ages, in both sexes, and among all classes.
There is scarcely a family, rich or poor, of which some member has not suffered at some pe-
riod in his lifetime, from eczema in a slight or more severe form. It is furthermore one of
the most annoying affections to which the skin is heir, and this fact, coupled with that of its
frequency, renders it beyond doubt the most important of all skin diseases and one with
which the physician should be most familiar. The disease is always amenable to proper
treatment, and in no field of medical practice can the physician more readily secure reputation
and reward than in the diagnosis and cure of Eczema.
The term eczema (from e« and Ctu ), meaning "to boil out," or "effervesce,'" implies a
catarrhal condition of the skin. A moist surface, or at least a tendency of the affected skin
to become moist through exudation of a gummy, albuminous serum, is the chief character-
istic of the disease. It has been claimed that a moist surface is always present at some time
in the course of the disease, but clinical experience shows that cases of erythematous and
papular eczema may remain dry from beginning to end. Even these cases, however, evince
a tendency to develop a moist sm-face upon slight external irritation, and moist patches are
not infrequently found upon an extensive eruption which elsewhere is perfectly dry. Fre-
quently patients will state that their eczema, now in its decline, has always been drj% and
the thickened patch of skin may appear to be due to increased cellular growth or some cause
other than infiltration of the sldn with a serous fluid. If the scaling epidermis be rubbed
briskly with soap and a piece of I'ough cloth it will be readily removed, and the catarrhal,
and hence the eczematous nature of the patcli, will be revealed by the minute pearly
(48)
ECZEMA ERYTHEMATOSUM
tOTTPE, E. BIERSTADT, N. Y.
ECZEMA.
beads of serum, which ooze out on the surface of the partially denuded corium. It is iLIj
tendency to exudation upon the surface of the skin which distinguishes a patch of eczema
from simple inflammation or dermatitis.
The exudation in eczema varies in amount, being so slight in some cases as not to appear
upon the surface, while in others it is poured out so abundantly that the whole epidermis is
washed away and a smooth red patch is exposed. It varies also in character. In some cases
the exudation is plastic, and being retained in the cutaneous tissue produces papulation on
the surface, and infiltration and hardening of the subcutaneous cellular tissue, while in other
cases it readily permeates the cells of the rete, and elevates the horny layer in the form of
vesicles. Upon the surface of the skin the exudation feels sticky, and cloths or banda<^es
soaked by it stiffen upon drying, and appear stained. In strumous and ill-conditioned sub-
jects, the exudation assumes a purulent character. This variation in the character of the
exudation results in a variety of lesions, no one of which has any claim to be regarded as the
special lesion of eczema. The disease is not merely a vesicular affection, as it was classed by
the earlier dermatologists, but is frequently papular and pustular as well, and in many
instances there is no vesiculation from beginning to end. When the surface exudation is
profuse, the serum dries and forms crusts. The crust of typical eczema is thin and dark,
cracking, and allowing the exudation to ooze from the cracks. Often it is composed partly
of dried blood, the result of scratching. When the exudation is purulent, the crusts are
lighter in color and thicker, increasing in bulk by augmentation from beneath. The exuda-
tion is sometimes of a thick, honey-like character, producing a bright yellow crust.
The thickening of the skin in eczema is most marked in chronic cases. It is partly due
to cellular infiltration, and partly to the exudation of plastic serum into the subjacent areolar
tissue. In acute cases and in parts of the body liable to passive congestion, e. g. the legs, a
temporary oedema often increases the thickness of the integument.
The itching of a patch of eczema is a feature which is rarely absent, but on the contrary^
usually present in a marked degree. In adults it is apt to be most troublesome in the ery-
thematous and papular forms of the disease. In children it is xisually severe, although, in
the jDustular form which occurs so often in those of a strumous diathesis, the symptom may
be much less marked.
The pathological process which takes place in the affected skin consists mainly in con-
gestion and cell-proliferation. In some cases the congestion is the main feature, and the-
affection is only to be distinguished from erythema by the characteristic pruritus and des-
quamation. In most cases, however, there are marked cellular changes, as has been shown
by microscopical examination. The disease in its mildest form may begin as a simple h j^iei'-
gemia. The skin becomes sightly thickened, itches more or less, and finally desquamates.
Usually, however, the initial hyperemia is followed by the development of papules, vesicles^
or pustules. Pruritus and exudation become prominent features, and eventually the affected
skin desquamates, as in the fonner instance. The disease, then, alwaj's begins in hyperaemia
and ends in desquamation. It is characterized by a tendency to moisture of the surfacf,
(49)
BISEASm OF THE SKIN.— INFLAMMATORY.
which may result in crusting, by infiltration of the deeper tissues which produces thicken-
ing, by the development usually of papules, vesicles or pustules, and by slight or severe
itching.
Following Willan. the illusti'ious pioneer of English Dermatology, some wi-iters ha\e
divided eczema into a mild variety {E. simplex), an inflammatory variety {E. rubrum), and a
purulent variery {E. im'petiginodes). This division is rather broad and indefinite, and as
many cases do not fall naturally into one of the three classes, it is of little practical value.
As a guide in the study of the disease, an aid in the description of cases, and a hint as to the
requisite mode of treatment, it is a better plan to divide eczema into stages through which
the majority of cases pass in their progress toward recovery, and to classify all cases in accord-
ance with certain well-marked clinical forms or phases assumed by the eruption, and to
which a special nomenclature is applicable.
The stages of eczema are three. The initial stage is characterized mainly by hypersemia,
with slight interstitial exudation, and in most cases by an eruption of papules, vesicles, or
pustules. Tliis lasts but a few days or weeks at the most before passing into the second
• stage, which is characterized by exudation and crusting. The extidation may be serous or
sero-purulent in character, and the inflammatory sjonptoms are usually well-marked. The
surface exudation destroys the integrity of the epidermis and dries into light-colored crusts
when not mingled with blood, which often flows freely from numerous excoriations. The
second stage of eczema is of indefinite duration ; but sooner or later the exudation subsides,
the crusts fall, leaving a thin, newly-formed epidermis, and we have then the third or term-
inal stage, characterized by desquamation and a certain amount of inditration of the affected
pait. In some instances-the initial stage passes directly into the terminal stage, without the
occurrence of extidation upon the surface or the development of any lesion besides the ery-
thematous patch, and not infrequently the third stage relapses into the second, the scaling
surface again becoming moist. Very often a case of eczema will exhibit the three stages on
different portions of the skin at the same tizne. At the spreading margin of an exuding
patch (second stage) we see hyperjemia and vesiculation (first stage), while a neighboring patch
may have become dry and scaly (third stage). The terms "acute" and "chronic," a, -i ap-
plied to eczema, are conveniently used in describing cases, and are always suggestive of the
appropriate plan of treatment ; but it must be borne in mind that these terms, as commonly
employed, do not refer so much to the length of time which the eruption has existed as to
the grade of inflammation which it presents. An eczema of thirty years' standing might,
therefore, during an exacerbation, be regarded as an acute eczema, and treated as such itntil
the inflammatory symptoms have subsided.
The clinical forms of eczema are numberless, and innumerable expressive tenns have been
coined and applied to them. It is simply a question of convenience whether we shall employ
five terms or fifty for purposes of description. Certain it is, however, that there are six strik-
ing phases assumed by eczema, and in accord with Wilson, the most admirable wi-iter on this
disease, the following clinical forms wiU be described :
(50)
ECZEMA.
1. Eczema erythematosmn (Pityriasis).
2. Eczema papillosum CLichen simplex).
3. Eczema vesiciilosum.
4. Eczema ichorosmn (E. madidans. E. rubnun).
6. Eczema pustulosum (E. impetiginosum).
6. Eczema squamosum.
The first two and last of these forms are always dry {E. siccum), while the remaining
three are more or less moist (^. Jiumidum), although the moist surface is sometimes concealed
by a crust. These forms of eczema may be accompanied by exceptional peculiarities, such at>
a circumscribed border, the existence of oedema, and the development of tubercles, fissure;^
or a warty surface. The term Eczema marginatum is applied to an erythematous or papulai
patch which does not shade off at its borders, as is commonly the case in eczema. The con-
dition is frequently seen about the genito-crural folds, and is likely to be confounded with
trichophytosis of this i-egion, of which it is sometimes a sequel. The tenn Eczema rimosum
{E. fissum) is used when a squamous or ichorous eczema of the hand or of the flexure of
joints is accompanied by the development of numerous fissures (see plate of E.squaviosum).
Eczema verrucosum indicates a warty condition, most frequently seen near the ankle, and gen-
erally in connection with ulceration. These accidental features are of little importance, and
cases of eczema exhibiting them will be found to fall naturally into one of the six divisions.
The older wi-iters on Deimatology were specially disposed to indulge in the use of a great
variety of adjectives to indicate the peculiar featui'es of eczema, and Bulldey has made a col-
lection of the terms thus employed, and has found that not less than one hundred and twenty-
five Latin names have been given to the phases of this one eruption.
Erythematous eczema, as the name implies, is characterized mainly by hypersemia.
There are no vesicles, pustules, or well marked papules, no moisture — nothing but a tolerably
smooth, reddened surface, with a moderate amount of fine desquamation. In its incipient
form it is merely a persistent erj-thema, with slight infiltration of the skin and consequent
pruritus. By scratching, or other external irritation, the skin may become considerably
thickened and covered with fine branny scales. This form (classed with E. squamosum by
Hebra, and described as pityriasis by older writers) is frequently met with on the face, and
usually predominates when the disease extends over the greater portion of the body. In the
plate of E. universale it is seen, together with patches of the ichorous and the squamous form.
When hyperfemia, which is the distinguishing feature of both erythematous and papu-
lar eczema, is not merely confined to the superficial network of blood vessels, as in the ery-
thematous form, but involves also the follicular plexuses, we have discrete congestive
papules developed upon a reddened patch of skin. This papidar eczema may be transitory
when produced by external agencies (a poultice of Avater-dressing, e. g.), but it is often chronic
and obstinate. When the congested follicles are not seated upon a hypergemic and infiltrated
patch, but are scattered in groups upon the normal skin, the term lichen simplex has been
(51)
DISEASES 0I> TEE SKIN.— INFLAMMATORY.
used to denote the condition. "\"\Tiile it is convenient for purposes of description to use the
old terms lichen and impetigo, it must always be borne in mind that they are not distinct
affections, but merely modifications of the papular and pustular forms of eczema.
Vesicular eczema was formerly regarded as the type of the disease. Vesicles, however,
are rarely present in cases of eczema when seen by the physician, and hence are of little use in
diagnosis. In many cases there has been neither vesiculation nor even a moist surface
throughout the course of the disease. The vesicular form of eczema is quite uncommon. It
consists of numerous small acuminate vesicles, crowded together upon a highly-congested
base. It may rim an acute course, and terminate in a week or ten days (and this is usually
the case when it is due to the action of some severe local initant), or the exudation may con-
tinue after a rupture of the vesicles, and the disease then assumes the ichorous fonn. Vesicu-
lar eczema attacking the face is often mistaken for erysipelas, especially when its outbreak
is accompanied by slight fever. The smooth, tense skin, Avith an abrupt margin of the patch,
is not seen, however, in eczema, and the speedy development of fine vesicles, or an exuding
surface, dispels all doubt.
In the ichorous, or moist fomi of eczema, we have the condition of most frequent occur-
rence. The affected part is swollen and tender, and the surface either presents a reddened,
raw appearance {E.rubrum), or is covered by a thin, dark crust, through which and beneath
which the characteristic gummy exudation appears. A^esiculation may or may not have
preceded this condition. The exudation may have permeated the epidermic cells and washed
them away en masse. Indeed, a moist surface may be present in some cases without even
destruction of the epidennis. When folds of skin lie in contact, as they do about the nec!c
and joints of fat babies, and beneath the breasts and in the inguinal region of obese females
the epidermis becomes macerated, and frequently assumes the character of epithelium. For
a short time the skin may appear as though converted into a mucous membrane, and dis-
charge a viscid serum {B. mucosum). Eczema ichorosum, in which the disease is at its
height, cannot be well confounded with any other affection of the skin.
The pustular form is in some cases not readily distinguished from the ichorous form.
The exuding s'jrum, instead of being clear and waterj", may be thicker, honey-like con-
sistence, and dry into yellowish crusts. The contents of the vesicles may assume a sero-puru-
lent character, or pustules may be scattered over the surface along with the vesicle, while in
either case yellowish or slightly brownish crusts are formed, which increase in thickness
from additions to the under surface. Pustular eczema is common in strumous and poorly-
nourished subjects. It is very apt to appear in connection with scabies and with phtheiriasis
both of the body and of the head. Isolated pustules are frequently developed when external
initation coincides wdth impaired energy, e. (/., after a season of intensely hot weather, but
it is an open question as to whether these are justly regarded as being eczematous in nature.
Though eczema commonly leaves no scars, this pustular form, the "milk-crust" of infancy,
sometimes pits the cheeks, and, even in later years, the child shows marks which might be
mistaken for the effect of variola.
(62)
ECZEMA.
The squamous form is the terminal stage of one of the other forms. It is but an ex;; "-
geration of the erythematous form — the acute hypersemia and. branny desquamation giving
place to thickening and induration of the skin and subjacent tissue, with exfoliation of the
epidermis. It sometimes occurs in patches upon the extensor siu-face of the extremities,
when it is with difficulty distinguished from psoriasis. The gi-adual shading ofl' of the
patches at the margins, contrasted with the circumscribed border of psoriatic scales, and the
existence of moisture beyond that condition which exists in psoriasis when tlie scale is re-
moved and the corium exposed, are features which 'ndll usually determine the diagnosis.
Squamous eczema, when universal, resembles Dermatitis exfoliati\a ; but in this rare affec-
tion the flakes of epidermis are much more abundant, there is no thickening of the ?kin, no
moist patches, no severe itching, and frequently there is a high grade of fever and great
prostration.
According to the German school, eczema is a local disease, and usually independent of
any constitutional vice or humor. External treatment is, therefore, of the greatest curative
value. The idea of "driving in" the eruption, or of its possible metastasis to some internal
organ is rejected, and the relapse Avhich so often occurs in eczematous patients is referred to
perverted cell-groMh of the affected part rather than to any disposition to the affection exist-
ing throughout the economy.
The French school has always been the champion of the constitutional nature of eczema.
The dartrous diathesis which, emigrating to Ameiica, appears as the rheumic diathesis, is
a term employed to indicate that general condition of which the eniption in eczema (and
psoriasis as well) is believed to be a mere outward expression. The local treatment,
according to the supporters of this view, is of minor importance, and a radical cure is only
to be obtained by remedies aimed at the constitutional defect.
The English writers on dennatology, while not generally accepting this view of the dia-
thetic nature of eczema, lay great stress upon it.s association with and dependence upon
gout, rheumatism, dyspepsia, etc., in a large proportion of cases, and are more disposed to-
favor a judicious combination of internal and external remedies. In America, these opposing-
views meet on a common ground, and time will tmdoubtedly declare the "survival of the
fittest.'"
The predisposing causes of eczema are not thoroughly understood. There are plenty to
be found outside of the profession who satisfy themselves by saying that it arises from " heat
in the blood," or " bad humor," or " scurvy," and there are many able writers in the pro-
fession who delude themselves into the belief that everything is clear when tlie disease is
ascribed to "assimilative debility," "perverted innervation," or to some favorite "diathesis."
Piffard, an able champion of the "rheumic." diathesis, claims that -eczema, psoriasis and
pityriasis exhibit certain general characteristics which indicate a mutual relationship, and
mentions the following features which they possess in common :
They are not contagious.
(63)
DISEASES OF THE SKIN.— INFLAMMATORY.
They are frequently general ; not, however, by simultaneous invasion of the surface, but
by spreading from dliferent foci.
They are frequently symmetrical.
They are usually chronic.
Their natural duration is indefinite.
They are obstinate and do not readily yield to treatment.
They are frequently observed in different members of the same family.
T^vo or more forms may be present at the same time, or may appear successively.
They do not always preserve their individuality, but sometimes merge one into the other.
Relapses are frequent.
They sometimes alternate with affections of other organs, especially of the pulmonary
and gasti-ic mucous membranes and of the joints.
niey itch.
The lesions are always superficial.
They never leave cicatrices.
They are more or less amenable to certain definite methods of treatment, which have
little if any effect upon oth^' cutaneous affections.
We know that eczema is frequently associated with a rheumatic tendency, and with some
of the many phases of dyspepsia, and that it is aggravated by poor food, intemperate habits,
care, and overwork Its association with dentition, gestation, worms, diabetes, etc., has
been noticed so often as to suggest a relationship, and the fact should not be lost sight of
when ( ailed upon to treat the disease. If not hereditary in many instances, it is certainly
more prone to occur among those who inherit the delicate and irritable skin, and the rheu-
matic and gouty tendencies of their eczematous progenitors. The exciting causes are mostly
local. Any continued irritant of mechanical or chemical nature wiD produce an eczema upon
almost any skin, and all the more readily when some of the predisposing causes exist. The
use of over-stimulating ointments in other skin affections — as sulphur in scabies, mercurial
ointment in phtheiriasis pubis — often evokes an eczema. Grocers, bakers, bricklayers, and
others engaged in pecidiar occupations, often acquire eczema upon the hands and other parts
exposed to the irritating action of sugar, lime, brick-dust, etc. Persistent moisture favors
the development of the disease, and hence infants and corpulent adults are often affected
where the folds of the skin come in contact. Washerwomen are very prone to a severe
eczema of the hands, which is often incui-able so long as the hands are frequently in water.
Diagnosis. Eczema is the most protean of cutaneous affections. Occurring, as it does,
at any age and upon any jiortion of the body, and presenting the greatest variety of lesions,
it is capable of assuming a similitude to almost any affection of the skin. In ordinary cases
it is readily recognized, but when it does not present a typical form it is frequently mistaken
for some other disease. The advice which has been jokingly given to call every doubtful
<Tuption a case of eczema is not at all bad, for in nearly every doubtful case the diagnosis of
eczema must be considered, and where the doubt can not be expelled the physician will do
(54)
ECZEMA.
better to consider it as eczema and endeavor to cure it by attention to the patient's genei-al
health, than to regard it as a possible manifestation of syphilis, and acting upon this suspi-
cion to subject the patient to an unnecessary course of specific medication.
In the diagnosis of eczema the characteristic symptoms of the eruption must be borne in
mind, and if the case in question presents redness and thickening of the skin, scaling or
crusting, a tendency to moisture, and a severe pruritus, the diagnosis is evident. But some
of these symptoms may be absent, and it will be often f oimd necessary to consider the char-
acteristics of certain other affections which may be suggested by the clinical appearances of
the case and then arrive at a diagnosis of eczema by a process of exclusion. The thickening
of the skin in eczema is sometimes too slight to serve as a basis of diagnosis and as has been
already stated, the moist surface is not an essential feature of the disease. The itching of
the skin, however, is always present and most serviceable in suggesting the eczematous nature
of the disease.
In the diagnosis of skin diseases in general it is often a good plan to regard them aU as
belonging to two classes, viz. : those which itch and those which do not itch. If the eruption
is not at all itchy (and to decide this point it is far better to look for evidences of scratch-
ing upon the skin than to inqidre of the patient), it is evident that it is not eczema, urticaria,
scabies, phtheixiasis or any other affection belonging to the first of the two classes. On the
other hand, if the lesions are excoriated and the skin decorated by numerous scratch marks,
we know that the eruption can not be of a syiDhUitic origin, or one of those of the second
class, in which there is little or no prui-itus. Unfortimately for the perfect working of this
plan of diagnosis there are some affections which, like erythema multiforme, burn or itch in
a slight degree — or like psoriasis, may cr may not itch — but nevertheless it often enables one
to narrow the possibilities of diagnosis to a considerable extent.
The erythematous form of eczema may be mistaken for erythema, erysipelas, rosacea and
pityriasis. Simple erythema differs from a mild case of erythematous eczema in a very sligh'
degree. There is no thickening of the skin, the surface not at all scaly save in exception?^ i
instances where an extensive desquamation follows the hypersemia and the sensation accom-
panying the eruption is one of burning rather than itching. Erythema multiforme is usually
distinguished by its characteristic localization on the backs of the hands, or by its margiiiate
configuration when occurring upon the trunk. When eczema occurs in an acute form r.pon
the face of an adult, the stidden redness and swelling of the skin is very apt to lead to a
diagnosis of erysipelas, but the absence of fever, the occtirrence of vesicles or surface exuda-
tion in place of bullse, and the course of eruption, will soon reveal the mistake.
Rosacea occiu-ring in old men with weather-beaten faces, often presents a counterfeit ap-
pearance of erythematous eczema of the forehead, nose and cheeks. In the former affection
the congestion is of a chronic passive character, and the skin feels cool to the touch, while in
the latter, the congestion is active, and accompanied by an elevated temperature and severe
itching. Pityriasis might be considered as the mildest form of erythematous or squamous
(65)
DISEASES OF TEE SKIN.— INFLAMMATORY.
eczema. In its clinical appearance it differs only in being more superficial, and not present-
ing the bright red color and annoying pruritus of eczema.
The papular form of eczema may be confounded with scabies, phtheiriasis, urticaria,
lichen planus and syphilis. In scabies, indeed, the eruption is nothing more than an artifi-
cial papular eczema, but the extent of the eruption, its peculiar localization, and the history
of contagion, even without the discovery of the characteristic burrows of the itch mite, will
serve to indicate the parasitic origin of the disease. In both scabies and phtheiriasis the
eruption is largely due to the action of the finger nails upon the skin, and there never co-ex-
ist patches of moist and thickened skin, such as inevitably accompany an extensive eruption
of papular eczema.
It should be borne in mind, however, that a secondary eczema is not infrequently pro-
duced in these parasitic cases by the irritation of the skin, and hence a double diagnosis is of-
ten necessary. Urticaria could not be mistaken for anything else if it were always seen at its
height, but inasmuch as the wheals have often disappeared when the patient seeks relief, and
nothing is left upon the skin but a number of excoriations and papules which have resulted
from scratching, the diagnosis of papular eczema can only be excluded after a consideration
of the history of the case. Lichen planus differs from papular eczema in the peculiar char-
acter of the lesions, which are low, flat, and often angular in outline, and with a shining sur-
face and a central depression. These lesions are very apt to form patches, but a tendency to
moisture or crusting is never observed. Lichen ruber is too rare and too severe a disease to
be often mistaken for eczema. The miliary papular syphilide, on the other hand, has fre-
quently jiassed unrecognized, and been treated for eczema until other undeniable manifesta-
tions of syphilis have made the error apparent. The eruption in the two affections may be
quite similar in appearance, although the papules of eczema are always of a brighter red hue,
and usually more or less excoriated. The concomitant sjTiiptoms of the syphilitic eruption
will usually decide the diagnosis.
The vesicidar form of eczema, when at its height, resembles the dermatitis which results
from ivy poisoning and the inunction of strong mercurial and other vesicating ointments.
It differs from these in its tendency to occasion a decided infiltration of the skin and a moist
"weeping" surface. This condition, which is the most tj-pical phase of eczema, could not
possibly be confounded with any other affection, unless it be intertrigo, in which the moist-
ure of the opposing surfaces of skin is chiefly sweat, and devoid of the sticky character and
tendency to stiffen the linen, which is the essential feature of the eczematous discharge.
The pustular form of eczema may be mistaken for sycosis, porrigo or favus. Between
eczema of the beard and sycosis a difference exists which is not admitted by all ^vl•iters. The
inflammatory process in the latter affection is deep-seated and the pus which forms in and
around the base of the follicles, loosens the hair and appears at the opening of the follicles
in the form of minute pustules, through each of which a hair passes. In eczema of the beard
there is a more uniform redness and swelling of the skin and the hairs are not loosened. Por-
rigo (or impetigo contagiosa) differs from pustular eczema in the size of the lesions and the
(50)
O
<
D
O
m
<
W
ECZEMA RUBRUM ET SQUAMOSUM.
ECZEMA.
character of the crusts formed ; while the latter are usually numerous, small and thickly
crowded and form a large, irn-egular dirty yellow or even brownish crust, the lesions of the
former affection are larger, circular and discrete, and form a lightly adherent straw-colored
crust beneath which there is a pinkish patch of skin with no moisture. When pustular eczema
has formed a thick yellowish crust upon the scalp it maj" bear a resemblance to the mortar-
like crust of favus, but the hair is wholly unaffected in the former case and there are no
bright yellow cup-shaped crusts at the mouths of the hair follicles as are commonly seen in
cases of favus.
The squamous form of eczema is most apt to be confounded with psoriasis or dermatitis
exfoliativa when severe and general, and mth the squamous syi)liilide when it is limited to
the palm. Eczema and psoriasis may be undistinguishable as far as the lesion of the skin is
concerned, but the shape of the patches, the general configuration of the einiption and the
history of the case serve as a basis for diagnosis. While in eczema the patches are rarely cir-
cular, and usually shade off into healthy skin at the margin, the scaly spots of psoriasis
or larger confluent patches are either circular or if confluent retain the sharply-defined border
of the original discs. While eczema is often unsymmetrical and especially liable to afl'tct
the flexures of the joints, the genital region and other parts where the skin is thin, psoria-
sis is usually remarkably symmetrical, and prone to affect chiefly the extensor aspect of the
extremities. The squamous form of eczema is subject to occasional exacerbations, at which
time a moist surface is very apt to develop. Psoriasis presents the peculiarity of increasing-
in intensity at certain seasons of the year, and nearly or qaite disappearing at regular periods,
usually through the summer mouths.
A general eczema bears a strong resemblance to dermatitis exfoliativa, but it does not, as.
a rule, involve every inch of skin, as is the case with the latter affection. Moreover, it pro-
duces a marked thickening of the skin which is notably absent in dermatitis exfoliativa. In
general eczema there are usually moist patches which are characteristic, but even in exfolia-
tive dermatitis these may be develojjed as a secondary eruption about the flexures of thv,
joints.
Eczema, when limited to the palms and soles, is extremely difficult in many cases to dis-
tinguish from a squamous syphilide. If the eruption is symmetrical and irregular in outline
and without a well-defined border, the probabilities are that it is eczema. On the other hand
if but one palm or sole is affected and if the eruption assumes a circular or semi-circular form,
is serpiginous in character, with an abrupt, elevated margin and a comparatively smooth
centre, it is usually safe to consider it as of syphilitic origin. The itching and cracking
which are supposed to be characteristic of eczema are symptoms which may likewise be
present in the chronic squamous syphilide of the palm.
Treatment. Among the laity there exist many absurd and erroneous notions regarding
eczema, and chief of these is the very common impression that certain chronic cases ai"^
incurable. It is true that many cases tax the skill and patience of even the physician who
has had a large experience in the treatment of skin diseases, but it may be positively stated
(57)
BTSEASES OF THE SEIN.—INFLAMMA TOR Y.
that every case of eczema is amenable to proper treatment. The great majority of cases, in-
cluding those which involve a large extent of cutaneous surface, and which are apparently of
the worst t\-pe, Avill yield at once if judicious methods are instituted. These measures are
necessarily various and miist be selected in accordance with the varying etiology of different
cases. While constitutional invigomting treatment is of the greatest importance in one case,
the next will require nothing beyond a careful selection of local applications. Most cases,
however, require a combination of both constitutional and local treatment to effect a radical
and speedy cure.
The constitiitional treatment of eczema may be summed up in the advice to improve the
patient' s health in every possible way. There is no routine plan to pursue, or at least there
should be none. Give tonics when needed, regulate the diet, improve the digestion, when
impaired, relieve existing constipation, if possible, and rectify all errors of hygiene.
Of tonics, a plentiful supply of fresh air, and where it is feasible, a change of air and
scene, is one of the most reliable in the treatment of eczema, as of numerous other ills. Iron,
quinine, cod-liver oil, and other remedies may be called for by the condition of the patient,
but these have little or no direct effect upon the diseased skin. The diet of the patient is an
important matter to consider, although eczema is less dependent upon gastric and intestinal
derangement than some of the other inflammatory affections, e. g., acne and urticaria. In
many cases the diet must be restricted in amount, or an increased amount of exercise strongly
insisted upon in order to ensure the perfect digestion of the food w^hich is taken into the
stomach. The amount of nitrogenous food consumed by many patients suffering from ec-
zema is greatly in excess of their needs and should be lessened. In hot weather I have gen-
erally found it advisable to prohibit entirely the use of meat. "When, as is frequently the case,
there exists an aversion to fat meat, often the result of whim or education rather than natural
taste, the patient should be encoiiraged to take plenty of cream, butter, or fat in some form.
Cod-liver oil, especially in strumous children, is frequently of the greatest benefit.
There is no specific treatment in eczema, no single remedy of pre-eminent value. The
administration of arsenic, as a first and last resort in every case, is a prevalent custom whirh
I must emphatically condemn. Arsenic is a valuable remedy in pemphigus and psoriasis, and
indeed in some cases of eczema ; but of so little value is it in the latter disease, as compared
with other remedies, that I very rarely find any occasion to prescribe it.
The value of purgation in eczema is debated. While not accepting the old idea of a
maieries morbi being carried out of the system in this way, I must say that clinical experi-
ence demonstrates that in many cases of both acute and chronic eczema, particularly of the
erj-thematous variety, the administration of purgatives for a few days wUl be followed by an
immediate and permanent improvement, and this, too, in cases which are not being treated
locally, or in which local applications have had comparatively little effect. Diuretics, by
.stimulating the kidneys, and thus relieving the skin of some of its functional duties, certainly
])roducc a most decided improvement in many cases of eczema, and are almost indispensable
\vhen treating patients with gouty or rheumatic tendencies. Our natural mineral waters have
(58)
ECZEMA.
a \ery beneficial effect in most cases of chronic and obstinate eczema, and the Ballston waters
which contain a large amoimt of lithia, I can especially recommend. Of the alkaline salts,
either the acetate or the citrate of potassium, in one or two gram doses (gr. xv. xxx.), will be
found of great service. This should always be taken well diluted, and either a half horn-
before or an hour after each meal.
Gelseminum, cypripedium and the bromides may often be given with good effect, especi-
ally at night, to lessen the intense prui-itus from which eczematous patients suffer.
The success of local treatment in eczema depends upon its adaptation to the case in hand.
Innumerable are the remedies which have been recommended, but without a knowledo-e of
the principles which govern its use, no remedy can be of much service. I ^^-ill venture to
assert, that so far as local applications are concerned, the great majority of cases of eczema
can be successfully treated \\-ith two simple ones, which are always on hand, or very easily
obtained, viz., sweet oil and soft soap. Of course, I do not advise the reader to use these,
since there are various emollient applications superior to the former, and stimidatino- reme-
dies which may ad\ antageously supplant the latter ; but I hold that it is far better to luiow
how and when to use even the two remedies mentioned, which typify two opposite modes of
treatment, than to have a well-stocked drug store at command, and to use its contents with-
out definite purpose. AVhat mil a bland oil or an emollient ointment accomplish in the
treatment of eczema ? It wiU soften and remove any crusts which may be present, it will
soothe the inflamed parts, and alleviate the itching, and it will protect the denuded corium
from the desiccating influence of +he air and the irritating action of water, and thus allow the
growth of a new and healthy epidermis. In the acute eczema of infancy, and in the acute
form of the disease, at whatever age it may be met with, it matters little what oil or ointment
or lotion be employed so long as it is the most soothing application that can be made. "What
wUl soap accomplish in the treatment of eczema \ It will free the surface of the skin from a
mass of dead epidermis, it ^^^.ll give exit to confined serum, it ^vill stimulate the circulation
of blood in the diseased skin, and thereby promote the absorption of the infiltrated products
of inflammation. In chronic cases, where there is thickening and induration of the skin,
with ])ersistent d-:^squamation and annoying pruritus, cases in which emollient applications
are utterly inefficacious, soap frictions will change the character of the eczema from a chronic
to a sub-acute form, a condition tending naturally to recovery. In fact, as in quinine in the
treatment of malaria, so is sapo viridis, or ordinary soft soap, in the treatment of chronic
eczema.
The widespread popularity of green soap is due solely to its therapeutic efficacy, and
exists despite numerous objections to it which might be raised. Though purporting to be
composed of potash and olive-oU, it is commonly made, as many are aware, of hemp-seed,
rape-seed, whale and other animal oils not always free from rancidity. Hence the offensive
odor of the green soap which is commonly obtained in the market. The saponification of the
soap is not always perfect, and it usually presents a streaky, variegated appearance. Its
(59)
DISEASES OF TEE SKIN.— INFLAMMATORY.
green color is artificial and due to the presence of indigo and other dye-stuflfs. It tends to
harden on exposure to the air, and finally its alkalinity varies to such a degree as to render
its effects more or less uncertain.
Some years ago a friend suggested to me the use of a substitute in the shape of a soft
olive soap used extensively in the manufacture of silli and other delicate fabrics. This 1 have
tried and found to be a similar, though far more elegant article than the ordinary sapo viridis.
It is made from cold-pressed olive-oil, and owes its green color entirely to the chloro-
phyl of the olive. As manufactured by Bagoe & Co., of New York, it is of unvarying
alkalinity, wholly free from unpleasant odor, homogeneous and, unlike the common green
tsoap, it gives a perfectly clear solution with strong or dilute alcohol. I have found it advan-
tageous to add to the soap a small percentage of glycerine, which, whUe counterbalancing the
natural loss of free water, renders it a most agreeable preparation.
The most common mistake made in the local treatment of eczema is in the application of
over-stimulating ointments and iiTitating lotions to parts which demand the most soothing
measures, and in the application on the other hand, of the oxide of zinc, or some other
slightly astringent ointment, to cases in which nothing short of soap frictions or some equally
harsh remedy will prove of the slightest benefit. At the risk of repetition, let me say again,
that the grade of inflammation determines the selection of a soothing or a stimulating plan
of treatment. If the affected part is swoUen and hot, pouring forth a profuse discharge, and
accompanied by an intense, burning pruritus, the local applications cannot be of too soothing
a nature. If the skin is dry, thickened, indurated and scaly, the local treatment can hardly
be too severe. Where the disease is extensive, as in Eczema universale, it is generally neces-
sary to vary the character of the treatment upon different portions of the body.
Such, briefly stated, are the principles which govern the local treatment of eczema. As,
in general treatment, the habit and idiosyncracies of the patient must be borne in mind, so
in local treatment must the character of the lesions be studied and routine practice avoided.
The reader must cast aside the vulgar notion that a wonderful therapeutic power dwells in
the remedy which is used, and learn that success in treatment is wholly due to the skillful
adaptation of remedies to the requirements of each case.
In acute eczema the pain and swelling which are sometimes present at the very outset of
the attack, may be relieved by the application of a cooling and sedative lotion, such as the
common mixture of lead water and laudanum. Lime water, " black wash," and the diluted
fluid extract of grindelia robusta, or hamamelis, have been highly recommended for this con-
dition of the skin. With the occurrence of exudation the application of a soothing and
protective ointment is preferable. The diachylon ointment recommended by Hebra, and
extensively used in Germany, is valuable if properly made, but the zinc oxide ointment of
Wilson is more commonly used in England and this countrj-, and on the whole is to be pre
ferred. A better application than either, according to my experience, is one recommended
by Lassar, and composed as follows :
(60)
ECZEMA INTERTRIGO.
rOTYPe, E. B1E.KSTADI
ECZEMA.
Salicylic acid,
• •
2 parts.
Oxide of zinc,
25 "
Starch,
.
25 "
Petrolatum to
.
. 100 "
M.
This is often the only local application which is needed in a case of eczema when seen
at an early stage, but when the acute inflammation has subsided, and especially when the
affection has reached its third or scaling stage, the return to a normal condition of the skin
will be hastened by the addition of live per cent, of oil of cade to the formula given above.
In chronic cases of eczema equal parts of tar and alcohol may be well rubbed into the
affected skin by means of a sponge or stiff shaving brush, and if this does not prove too
stimulating for the condition of the skin which is present, it wall certainly tend to allay the
itching, and lessen the thickening which has taken place as a resiilt of the prolonged intiam-
mation. Chrysarobin is a most valuable remedy in many cases of chronic eczema, and may
be applied in the form of a pigment or varnish, prepared by suspending the powder in coUo-
dium or the solution of gutta percha, or in the form of the following ointment :
51 Chrysarobin, .... 5 parts.
Salicylic acid, . . . . 6 "
Petrolatum to . . . 50 "
M.
It should be borne in mind that this ointment will stain and ruin the bed linen and
underclothing of the patient while it is curing the eczema, and the patient should therefore
be made acquainted with this fact. Eecently a novel and efficacious method of treating
eczema by means of medicated glycerine-jelly has been highly recommended by Pick, Unna,
Morrow and others, and bids fair to become generally popular. This jelly is prepared by
boiling together one part of gelatine and three or four of glycerine until they form a trans-
lucent mass. To this any medicament, such as oxide of zinc or chrysarobin can be added.
When ready to be used a sufficient quantity of the soft tenaceous mass can be melted in a
cup, and the warm liquid jelly painted over the affected skin by means of a stiff brush. It
dries quickly and forms a thin, flexible, artificial cuticle.
The question as to whether the rapid cure of eczema may prove prejudicial to the patient
has been freely discussed. The experience of nearly all dermatologists answers this with an
emphatic negative. No peccant matter is ever eliminated from the system in the foi-m of an
eczematous discharge, and under no cirumstances can the disease be regarded as salutary. It
is true that the eruption, in rare instances, seems to alternate with affections of the respiratory
apparatus ; but this merely shows that inflammation of the skin is not apt to co-exist with
inflammation of an internal organ. If a child imder treatment for eczema is exposed to cold
or injured by a faU, and contracts pneumonia or meningitis, the eruption naturally subsides,
in consequence of the determination of blood to the lungs or brain. The rapid cure of
(61)
DISEASES OF THE SKIN.— INFLAMMATORY.
eczema, instead of being the cause, is rather the result of the internal phlegmasia. In this
■waj' an eruption maj- be said to be dl■a^vn in, but it is impossible for local treatment to drive
it in. I have no doubt but that in some cases of infantile eczema harm has resulted from
the application of strong mercurial ointments to a large extent of skin ; but it has been the
mercurj- and not the disease which has been driven in. Death or severe illness, from what
ever cause, is preceded by the subsidence of any eczematous discharge which has pre-existed,
and Ulogical friends of the patient are not only liable, but often disposed, to mistake the
cause for the eifect.
ECZEMA INFANTILE. The occurrence of eczema in infants and children under five
years of age is so common, its clinical appearance so marked and its treatment so peculiar,
that for practical purposes eczema of infants might be considered as a distinct affection from
eczema of adult life. It occurs among the rich as well as among the poor, although less
likely to assume an aggravated form when the child is properly cared for. It often com-
mences immediately after birth, or when the infant is but a few week old, persisting, if not
properly treated, for several years. It runs a somewhat irregular course, appearing better
and worse from week to week, the occasional exacerbations of the disease being usually
unaccountable. The disease is a most annoying one in all cases, not only to the little sufferer,
but to the mother or nurse who has charge of the case, Avhose sleep is so frequently broken by
the child's distress.
Eczema of infants is most common tipcn the scalp and face, and this locality is generally
affected when eczema is present. In addition there may be patches of the eruption upon the
tnmk and extremities, involving a considerable portion of the integument. Upon the scalp
the eruption usually affects the anterior portion, except when pediculi are the cause of the
trouble, in which case the UTitation and scratching almost invariably produces an eruption
upon the occiput. The seborrhoea, which so frequently forms a dirty, gi-easy and persistent
coating upon the cro^vn of the infant's head, is very frequently the starting point of an
eczema which may occupy the same location or spread down upon the ears and simultaneously
affect the cheeks. When the hair is scant the eruption upon the scalp presents a red and
crusted or scaly appeaiance, quite similar to the patches upon the face ; but in older children,
whose hail- is thick, the chief feature of the eruption is the mucilaginous discharge, which
occui-s here and there as portions of the scalp become torn by scratching or irritated in any
way, and which tends to dry and produce an appearance as though a little gum arable had
been poured upon the head and allowed to dry on the hair. This characteristic gumming
together of bundles of hair will often enable one by the sense of touch to make as positive
a diagnosis of eczema as could be made after the most careful examination of the scalp.
Upon the face the eruption, when at its height, is generally moist and covered with a
crust which results from the drying of the characteristic gummy discharge. This alone pro-
duces a thin crust like a coat of varnish which cracks whenever the skin becomes more
inflamed and swollen, and the discharge oozing through these cracks in the epidermis and
drying gradually causes a thickening and a very irregular surface of the crust. Such a crust
(62)
ECZEMA.
is u.^uaUy quite adherent, unless cast off by a swelling of the skin and a greatly increased
discharge, in which case a red, raw and angry looking patch is exposed, which becomes
quickly covered by a new crust. Where pus is mingled Avith the discharge from the skin, as
is usually the case in certain forms of infantile eczema, the crust is always thicker, more
friable, and of a dirty yellowish hue. Such a crust may remain upon the skin until the
inllammatory condition beneath has in great part subsided and then be cast off, leaving a dry,
reddened and scaling surface. In many cases cf eczema of the face in infants the cheeks are
merely reddened and thickened, but not exhibiting any discharge excppt at numerous points
where the skin has been excoriated by the nails and covered with dark blood crusts.
In the etiology of infantile eczema there are certain special factors to be considered in
addition to those which have already been mentioned. An inherited, or at least a congenital
tendency to eczematous inflammation cannot be denied in many cases, and such are often
difficult to cure as the active cause cannot be demonstrated. In many cases an improper diet
is a potent factor in the production of the eczema which will yield with surprising rapidity
when careful attention is paid to this point. Teething, to which the eruption is so frequently
attributed by those having care of infants, has nothing to do with the causation of infantu'e
eczema. Nor has vaccination any etiological importance, in spite of the firm belief of many
fond parents to the contrary.
The frequent washing of an infant or child affected with eczema, is one of the most com-
mon of means unconsciously employed by the mother or nurse to aggravate the existino-
inflammatory condition. Many cases can be cm-ed by doing nothing more than insistino- upon
total abstinence from the use of soap and water.
The diagnosis of infantile eczema is always easy when the characteristic exudation is
present. When the eruption is dry, scaly or crusted mistakes sometimes occur. At an early
age the outbreak of inherited syphilis might be confounded with it, but it should be remem.
bered that the lesions in such a case are especially liable to accumulate about the mucous
orifices, are circular in form when diy, and do not present any symptom of severe itchrno- even
when moist. Scabies in young children is liable to be considered as a papular eczema, and
the lesions indeed are indistinguishable, but in the latter affection the history of conta"-ion
where the children sleeping together are all affected, the limitation of the eruption to the
trunk and extremities, and the discovery of the burrow of the acarus upon the soft skin be-
tween the fingers or elsewhere will reveal the parasitic origin of the eruption.
Urticaria occuring in children is frequently called eczema. An itching and excoriated
skin is to be found in either affection, but patches of eruption are only met with in the latter,
while the history which is given of the sudden outbreak and speedy disappearance of red or
white lumps poiats clearly to the former affection.
Treatment. In caring for a case of infantile eczema, it is essential that the physician
should not only understand what to advise, but he should also see that his advice is followed.
Otherwise his sldll and advice are of no avail. All directions given must be explicit, and it is
usually advisable to have them repeated by the mother or nurse, in order to make sure of their
(63)
DISEASES OF THE SKIN.— INFLAMMATORY.
being undfci'scood. In very many cases it is the neglect of certain directions, apparently
of minor importance, rather than any peculiar obstinacy of the eruption, which renders the
treatment tedious and sometimes futUe.
The diet of the infant is usually the fii'st point to be considered, with a view to removing
the cause of the eruption. In the case of infants at the breast, it is a very common custom
of mothers to nurse the child whenever it cries; and as the crjnng usually results from a dis-
ordered digestion, the practice of giving the breast every half hour only adds to the child's
discomfort and aggravates the eruption. If the mother's milk is insufficient in quantity, or
not of proper quality, it is much better to wean the infant at once, except in mid-summer,
than to attempt to supply the deficiency of nutrition by a partial resort to artificial feeding
After weaning it is a common custom, especially among the poorer classes, to give the child
everything which is on the table, including tea, coffee, picldes, pastry, &c., the impropriety
of which must be duly impressed upon the mind of the infant's nurse or mother. Even
among the more intelligent classes, the eczematous chUd, whose appetite is usually good, is
too often allowed to eat at irregular intervals ; and at my college clinic I have sometimes
taken a number of eczematous infants before the class, each with an apple, a cracker or a
piece of candy or sugar in one or both hands. This constant feeding between meals is a fre-
quent source of indigestion in young children, and always tends to aggravate an already
existing eczema. A strict injunction to allow the child no solid food, except at its meals, of
which it may have four daily, will often produce a decided improvement in the character of
the eruption. The bowels should be regulated in many cases, and when, as often happens,
the stools are found to be unusually light colored, a mild calomel purge once or twice a week,
as recommended by Wilson, wiU prove of the greatest benefit. The alkaline diuretics which
are so frequently called for in the treatment of eczema of adults, may be given for a few
days to children whose urine is acid and irritating to the skin of the genital region, but a
solution of magnesia or lime water will usually have a better effect and can be continued for
a longer time. Of other internal medicines, arsenic and viola tricolor have been especially
recommended, but my experience has led me to rely mainly, if not wholly, upon hygienic
and dietetic measures combined with local applications.
The value of fresh air as a curative agent in infantile eczema is rarely appreciated as it
should be. Its immediate soothing effect ui^on an eczematous infant who has persistently
refused to sleep, or to refrain from scratching for more than a half hour at a time, is often as
surprising as it is delightful. It is sometimes difficult to have a child taken out of doors on
account of the foolish notion that it is too hot or too cold, too windy or too damp, and often
the parents object to having the little sufferer appear in public with its head and face band-
aged ; but when removed from a hot and close atmosphere to the pm-e open air for a half hour
to an hour or two daily, according to the weather, the beneficial effect upon the eruption will
soon be noticeable.
In the use of local applications to the eczema of infants, patience, perseverance, and
above all, intelligence, are required. The main object should be to soothe and protect the
(64)
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ECZEMA.
skin. For this purpose the application which I have formd to be the very best of many
which I have employed, is the following :
'^ Salicylic acid, ... 2 parts.
Subnitrate of bismuth, . .30 "
Com starch, ... 20 " '
Ointment of Rosewater to 100 " *
M.
This should be spread thickly on pieces of stout muslin and carefully applied, so that
every portion of inflamed and moist skin should be smoothly covered. Where there is merely
a dry squamous form of the afl:ection present, it can be rubbed over the surface of the skin
by mean.'? of the finger. The application being pasty rather than oily in character, is more
adhesive than the ordinary ointments which have been recommended, and is not so easily
rubbed off. Indeed it maj- be repeatedly applied until a thick, white and rather dry coating
forms upon the surface of the skin, which lessens the itching and the redness, and allows a
healthy epidermis to form.
Upon the scalp this ointment or paste is not to be used on account of its tendency to mat
the hairs together. Upon this region an oily application is preferable. If thick crusts are
present they should be removed by a poultice or the application of an oiled sUk skuU-cap.
When removed, the following may be rubbed into the scalp night and morning :
9 Oil of Cade,
Almond oil, equal parts.
M.
The oiled silk cap may be continued to be worn, and will not only protect the bed-linen
fi-om becoming soiled by the tar, but will itself have a good effect upon the eczematous scalp.
ECZEMA OF THE SCALP. In adults eczema of the scalp is by no means as common
as among young children. Xor is it as common as eczema of other portions of the body. It
is often persistent, however, and demands the most skillful treatment. Its course is gener-
ally a chronic one, and although there may be at times a moist discharge at one or more
points the eruption is commonly of the squamoiis type. The crown of the head is its favorite
seat, and in some cases the ears are simultaneously affected. The affection begins insidiously,
and considerable itching is often endured before the patient discovers the presence of one or
more scaly patches. Examination now shows that the affected jDortions of the scalp are red-
dened and considerably thickened. The affection is subject to occasional exacerbations, and
may subside spontaneously to such a degree that for a while the patient is comparatively free
from annoyance. The growth of the hair is never affected in any appreciable degree by the
presence of the eruption.
The cause of eczema of the scalp is not always apparent, but even the patient ^^-ill usually
discover that it tends to become aggravated by all attempts to get the scalp clean througli
frequent washing oi digging at the scales with a comb.
(65)
DISEASES OF THE SKIN.— INFLAMMATORY.
The affections with which eczema of the scalp is apt to be confounded are seborrhoea
psoriasis, and in certain instances a tubercular syphilide limited to this portion of the body.
In sebon-hoea capitis, as has already been stated, there is but slight if any redness of the scalp,
and the scales are soft and unctuous in character. While with eczema capitis the ears are apt
to be involved, with seborrhoea capitis the nose is more apt to be simultaneously aifected.
Psoriatic patches upon the scalp bear a very strong resemblance to eczema, but they are usu-
ally circular and marginate in form and rarely exist without patches of psoriasis upon other
portions of the body, which serve at once as a key to their diagnosis. A tubercular syphilide
affecting the scalp likewise possesses this abrupt margin. But it is unaccompanied by pruri-
tus, and the nodules seen upon a careful examination of the scalp tend to softening and
ulceration, which in time results in cicatrization and partial baldness.
Treatment. One of the very best applications for the cure of eczema of the scalp is the
oil of cade. It may be applied of full strength, even when there is a slight amount of moist-
ure present, for the scalp appears to tolerate the stimulant action of this remedy when a simi-
lar moist eczema of other parts would only be aggi*avated by it. As the odor and color of
this application render its use objectionable in many cases, in private practice a less efficient
remedy must often be employed. When there is but slight thickening of the skin a little
ammoniated mercury ointment may be rubbed into the scalp with the finger every night and
morning, and when the itching is very annojdng an ointment of naphthol of from three to
five per cent, may be advantageously employed. It is hardly necessary to say that a thin
layer of ointment smeared over a thick crust will have no effect upon the diseased skin be-
neath. Cutting the hair short facilitates treatment ; but in the case of women and young girls
who are reluctant to be cropped, it is never absolutely necessary.
ECZEMA OF THE FACE. An acute attack of eczema may occur upon the forehead
and cheeks, assume the vesicular form and be accompanied by considerable burning pain and
swelling. This usually runs its course in from one to two weeks, although where an eczema-
tous tendency is present the eruption may assume the chronic form. For this condition a
dusting powder of bismuth and corn starch or a lead lotion is advisable during the inflam-
matory stage, and a bland ointment to be applied when the skin begins to desquamate.
Eczema of the face, however, usually assumes a chronic erythematous form in adults, and
is most apt to affect the eyelids and neighboring parts. The eruption begins with a dry,
harsh and intensely pruritic condition of the skin which gi-adually becomes thickened and
covered with, a mealy desquamation. The skin presents a pinkish or light-red hue and there
is rarely any moisture of the surface from beginning to end. The natural furi'ows become
deepened, and the itching is of such a character as to render this eruption one of the m ost
annoying that could be imagined, especially when the patient is of a highly nervous tem-
perament.
In appearance, erji;hematous eczema of the infra-orbital region may bear a close resem-
blance to rosacea at first glance ; but while the hyperemia is passive and the skin is cool in
I he latter affection, the skin is actively congested and elevated in temperature in the former.
(66)
00
O
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X
CL
O
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u
ex
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ECZEMA.
It can be readily distinguished from erythematous lupus, which often presents a similar hue
and slight amount of desquamation, by the absence of the marginate border Avhich is alwaya
present in the case of lupus.
Teeatjient. Until the congestion of the face can be lessened by attention to the digest-
ive functions, and perhaps by mild purgatives continued for several days, a lotion of hama-
melis may be kept applied to the affected skin by means of saturated linen cloths. This -Ail]
give temporary relief, though it may have no curative effect. A mildly stimulating ointment
is now advisable ; and the following is one which has jdelded excellent results in my liands ;
9 Oil of Cade. 5 parts.
Ointment of oxide of zinc, to 50 "
M.
ECZEMA OF THE BEARD. The bearded portion of the face is the seat of several
skin affections, chief of which are eczema, sycosis and trichophji:osis. These affections, when
attacking the beard, present no important features which are not present when they occur
upon the scalp or elsewhere. Eczema of the beard, though naturally occurring only in adult
males, tends to assume a severe grade of inflammation, but differs in no essential regard from
eczema of the scalp. Sycosis is an affection which generally attacks the beard, but in rare
instances it occurs on hairy parts elsewhere, and presents the characteristic features of the
disease, viz., suppurating nodules, developing about the roots of the hairs. Trichophytosis,
or "ring- worm" of the beard, has, in the great majority of cases, the same features as when
met with upon the scalp and non-hairy parts, and does not deserve a different name. Indeed,
much confusion has been introduced into dermatology by the application of different names
to the same disease occurring on different portions of the body.
Eczema of the beard is characterized by the symptoms of eczema in general, redness,
burning or itching, exudation, with a tendency to the formation of crusts, and finally, thick-
ening of the skin and desquamation. Some writers claim that a pustular eczema of the beard,
which of all the forms of eczema bears the closest resemblance to sycosis, can be distinguished
from the latter by its extending beyond the hairy parts, upon the cheeks and neck, whereas
sycosis is strictly limited to the hairy parts. This point is not always to be relied upon. In
a large number of cases, the eczematous nature of the eruption is clearly sho\vn by its
occurrence upon those favorite localities, the ear and eyelids, but its tendency to attack and
confine itself, like sycosis, to the hairy parts, is shown by its presence in the pubic region,
and its conspicuous absence beneath the oomers of the mouth, where the growth of the beard
has not begun.
The first step to take in the treatment of eczema of the bearded portion of the face is to
dispose of the beard. This may be clipped very closely mth fine scissors, shaved, or pulled
out, as the necessities of the case demand. When the eruption is crusted, or the skin acutely
inflamed, and exuding freely, shaving is for the time almost impossible. The hairs should be
cut as short as possible with scissors, when, by a poultice or repeated inunction of oil, the
(67)
DISEASES OF TEE SKIN.— INFLAMMATORY.
crusts can be removed. If now the skin is tender, and shaving proves to be a painful opera-
tion, it is -well to continue the use of the scissors in preference to the razor. In the majority
of cases, however, shaving can and should be performed at least thrice weekly, while the or-
dinary treatment for eczema is can-ied out. When the affected part is hot, swollen, and dis-
charging serum, I have seen excellent results follow moderate purgation kept up for two or
three days, combined with hot fomentations, or the application of the zinc oxide ointment
spread on soft rags, and held in place by a bandage. An infusion of senna or viola tricolor,
or the compound jalap powder may be used as a purgative. When the acute inflammation
has subsided under the iafluence of emollient applications and due attention to the patient' s
general health, and the eruption has assumed the character of a dry, reddened and scaly
patch, the officinal ointment of sulphur or of the nitrate of mercury may be used, diluted
with from three to five parts of cold cream. When the morbid process shows a tendency to
extend from the surface to the deeper portion of the hair follicles, the skin usually assumes
a liunpy appearance resembling sycosis, and pustules develop around the hairs. In such a
case, the treatment already mentioned is of but little benefit, and epilation is called for. The
hairs are usually firm, and consequently extracted with pain. A small drop of blood occa-
sionally follows the epilation of certain hairs, but this only acts as an antiphlogistic, and the
improvement within twenty-four hours is often as surprising as it is pleasing. To aUay the
pain I have in some cases held a piece of ice in contact with the skin for a few minutes before
extracting the hairs. When the inflammation has attacked the deeper parts, the hairs are
loosened, come out with gentle traction, the root sheaths being bathed in pus. In such cases
the excessive suppuration is apt to destroy the foUicles, and lead to permanent baldness of
the part.
ECZEMA OF THE EARS. "While in children eczema is very frequently observed be-
hind and around the ears, among adults the disease is more liable to affect the auricle itself,
and the external auditory meatus. The affection is usually a chronic one. although at times
an exacerbation occurs, and the skin becomes the seat of a moist discharge. When the dis-
ease has persisted for months or years, as is sometimes the case, the auricle becomes swollen,
indurated, and scaly. Its natural pliability is completely lost, so that the patient is unable
to rest the head at night except upon the occiput, and even then a painful fissure is very apt
to form in the post auricular furrow.
The diagnosis of eczema of this region is very simple in the majority of cases. Erysipelas
and erythematous lupus can be distinguished by the febrile condition accompanying the
former disease, and the marginate character of the patches and the absence of itching which
characterize the latter affection. Psoriasis sometimes occurs in the form of a scaly jiatch be-
hind the ear and extending upon the auricle, but it is never limited to this region, as may be
the case with eczema, and the presence of psoriatic patches elsewhere will settle the diagnosis.
Treatment. Chronic eczema of the auricle is generally an obstinate affection, and yields
reluctantly to the most judicious treatment. To lessen the infiltration of the skin, which
should be our main object, a stimulating application is required. An ointment containing tar
f66)
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ECZEMA.
naplhol or ammoniated mercury fulfils this indication, while keeping the scales softened au>t
removed and protecting the skin from the irritating influence of the air. A pasty ointment
which will adhere to the skin is preferable to a greasy ointment which will soak into the
clothes upon which it is applied, and the following will be found of service :
9 Calomel, 15 parts,
Starch, 10 "
Oil of cade, . . . . 5 "
Petrolatum to . - . - 50 "
M.
When eczema affects the external auditory canal there is often but a slight redness and
scaliness to be seen, but considerable annoyance is experienced by the patient. The constant
digging at the ears with the finger, a pin, or some other instrument, to which the patient i-e-
sorts for the temporary relief of the itching, only aggravates the trouble, until in time such a
thickening of the membrane and resulting desquamation is produced that the canal is ]iar-
tially occluded and slight deafness is occasioned. A purulent discharge is sometimes present,
and the obstinacy of the affection under such circumstances, a fact noted by most aurists,
may be due in gi-eat part to frequent syringing of the canal with soap and water. As the
frequent application of water is usually harmful to eczema of any part of the body, it is ad-
visable to direct the patient to abstain from its use in cleaning the auditory canal. The scales
which accumulate rapidly must of coarse be removed, but this can be done by the use of a
large camel's hair pencil dipped in oil or in oxide of zinc ointment made thin by the addition
of glycerine. When the canal is clear and the discharge has ceased the oil of cade may be
applied readily by means of the brush, and usually with good effect in lessening the annojdng
pruritus and restoring the skin to its healthy condition. When the grade of inflammation is
extremely chronic and there is much infiltration of the skin, extending even to the membrana-
tympani, the application of a strong solution of nitrate of silver has been strongly recom-
mended. In my experience the use of a two per cent, ointment of chrysarobin has been pro-
ductive of the best results.
ECZEMA OF THE HANDS. Although eczema may attack either the palmar or the
dorsal surface of the hands, it rarely occurs in a marked degree upon both at the same time.
One hand only may be affected, although the disease is commonly found on both, and is
sometimes quite symmetrical. On the back of the hand, eczema is more apt to be of internal
origin, and to co-exist with patches on the arm or elsewhere. When of long standing it may
be papular or squamous, but it usually assumes the ichorous form. On the palm, eczema
differs in many respects from the disease as it occurs elsewhere, and demands a peculiar mode
of treatment. As met with in practice it is usually dry, and characterized by homy scales,
and by deep, painful fissures occurring in the lines of flexion. Sometimes the whole palm is
affected. More frequently the disease occupies but a portion, and appears as a single diffused
patch or a number of isolated scaly patches of a more or less circular form. Eczema of the
(69)
DISEASES OF THE SKIN.— INFLAMMATORY.
palm is usually chronic (in one sense of tlie term) from the verj' outset. It begins at one or
more points with redness and itching, and after much gentle scratching or rubbing with the
hand it develops into a somewhat thickened and scaly patch. This increases in size by peri-
pheral extension, or creeps over the palm with a circumscribed and curving border, very much
like a squamous syphilide. There is a wide variation in the appearance of different cases.
Upon a soft-skinned palm, the redness, infiltration and desquamation of typical eczema are
seen, while in another case nothing is apparent but whitish patches of hornj^ epidermis, which
the patient is constantly picking or digging with the finger-nails of the other hand. "Where
much infiammation is present of an acute grade, the palms become swollen, and numerous
fissures result from flexion and extension of the hands, until the latter become too painful to
be used, and are held by the patient like claws, in a rigid and semi-flexed position. In old
cases, where the outer layers of epidermis have been gradually'' removed, the skin of the
palms is notably reddened, feels harsh and dry, though quite smooth, and the natural lines
and f un-ows are greatly exaggerated. When the fingers in such a case are forcibly extended
the blanching of the palm, which occurs to a slight degree in a healthy hand, is well marked
and characteristic.
The diagnosis of eczema of the hands is usually simple. Palmar eczema, however, may
bear such a strong resemblance to scaling syphilitic patches that experienced dermatologists
are often unable to make a positive diagnosis from a mere study of the lesions. According
to text-books, eczema presents irregular patches, covering perhaps the whole palm and itching
severely, while syphilis is characterized by smaller circular patches, with more infiltration of
the skin, a circumscribed border, and an absence of itching. But there are very many excep-
tions to this rule. Eczema may occur in a form of small circular patches and in the center of
the palm, may have a well-defined border and spi'ead over the palm in a serpiginous manner,
while a palmar syj^hiloderm may itch and crack and be aggravated by iDutting the hands in
water, and, in short, appear exactly like an eczema. I know of but one infallible rule to
apply. If a number of small scaly spots are arranged in a semicircular or horse-shoe form,
•with an inclosed area of healthy skin, or if a spreading circular patch exhibits an infiltrated
margin and a healthy or healing center, the patch is of syphilitic origin. In a doubtful case
the history of the patient is of little value, as the palmar syphiloderm, liable to be con-
founded with eczema, is a late manifestation of the disease, and so many syi^hilitic persons,
particularly females, are unaware of ever having contracted the disease. The scaling papules,
accompanying or following the early secondary eruption, ought never to be mistaken. Even
with a clear history of sj-philis, eczema may occur as an independent affection. " Psoriasis "
is a term applied by many to every scaly palmar patch, irrespective of its etiology, but among
dermatologists the term "syphilitic psoriasis"' is rapidlj^ becoming obsolete. True psoriasis
is of so rare occurrence upon the palms that it is not likely to occasion an error in diagnosis
in many cases, and as it is very rarely if ever limited to the palms, the presence of the char-
acteristic white scaly discs upon other portions of the body ought to prevent its being con-
founded with eczema of the palm.
(70)
ECZEMA.
The local treatment of eczema occurring on the backs of the hands requires no special
directions. Soap frictions are useful in the papular form, accompanied wdth induration of
the skin, and even in the case of moist patches, soap, though a harsh remedy, may be used
once or rwioi^ to remove the dried exudation and dead epidermis in order to give a free exit
to the confined serum. Thf> diachylon ointment may then be spread thickly on pieces of soft
cloth, and kept constantly applied to the moist, reddened surface. The affected fingers may
be bandaged separately and tightly, and the hands must be kept out of water until a new
epidermis has formed and there are no more fine beads of exuding serum.
Eczema of the palm requires a method of treatment quite different from that of eczema
elsewhere. The thickened epidermis must be removed, the painful cracks healed, and the
infiltration of the corium absorbed. The skin must then be kept in a soft, pliable state, until
the redness has in i great measure faded and there is little tendency to itching and scaling.
Though the occasional dipping of the hands in water is harmful, there is scarcely a bet-
ter nil xle of lessening the intiammation, and at the same time macerating the epidermis than
by ordering the patient to place the palms in a shallow vessel containing a little more than
enough water to cover the bottom. The water should be as hot as can be borne, and the palms
kept in it for at least fifteen minutes at a time. "When there are horny patches, unaffected
by the water, glacial acetic acid, or liquor potassse applied on a glass rod will be found to
soften them quickly. These strong applications must be handled with care, lest severe pain
be caused by their getting into the cracks. But the cracks are merely the result of the
thickened and indurated epidermis, and it is iiseless to heal them and have them break
open again. If their ciush, viz., the thickened epidermis, be removed, they will heal of
themselves and remain healed. Rubber gloves worn constantly (with the rubber side next
to the skin) act beneficially in most chronic and obstinate cases. After the thickened epider-
mis has been removed and the cracks healed, the palms may remain for a long time reddened,
dry and harsh, \vith a constant tendency to become worse again. An ointment containing
ten per cent, of oil of cade in vaseline does well in such cases, but success \vill depend less
upon local measures than upon tht internal treatment adapted to eczematous cases in general
and to this patient in particular.
ECZEMA OF THE FEET. Most of what has been said of eczema of the hands will
apply to the disease as it appears upon the feet. Here it may exist alone or it may co-exist
with eczema of the hands. If severe it usually interferes with locomotion. Between and
around the toes the eruption is apt to assume an acute form, and the toes must be bandaged
separately like the fingers, or kept apart from one another by the intei-position of absorbent
cotton. A honiy condition of the soles can be advantageously treated by the repeated appli-
cation of the following lotion :
9 Salicylic acid, .... 10 parts.
Alcohol to . . . . . 100 "
M.
(")
DISEASES OF THE SKIN:— INFLAMMATORY.
ECZEMA OF THE AISTJS AND GEISTTTAL REGIOjST. The anus, perinc-pum. vulva,
penis and scrotiun are often the seat of eczema, and though the affection in this region is
usnally quite limited in extent it is capable of producing the greatest amount of annoyance
and even distress. In many cases there is simply intense pruritus with very little redness
and thickening of the affected skin. In other cases there is to be found a decided infiltra-
tion of the skin with more or less scaling and a marked tendency to the production of fissures
and excoriations Finally there are cases in which the vulva of the female and the glands and
under surface of the penis and the sides of the scrotum in the male are entirely denuded of
epidermis and exquisitely tender. In these cases the sufferings of the patient are almost
intolerable. Locomotion is difficult, refreshing sleep is unattainable and daily existence is
fraught Avith misery.
Treatment. Success in the treatment of eczema of the anus and genitals usually de-
pends upon the abiUty of the physician to discover and remove the cause of the eruption or
the conditions which tend to aggravate it. Local treatment is always valuable as a means of
palliating the symptoms, but it rarely proves curative, and the common mistake should be
avoided of depending wholly upon external treatment.
In eczema of the anus a disordered digestion is almost invariably at the root of the
trouble ; and attention to diet is worth more than all the ointments or lotions ever recom-
mended. The patient is usually constipated, although he may assert that his bowels are per-
fectly regular, and, iadeed, as a result of training, they may move once a day. A tendency
to hemorrhoids is a usual concomitant of the itching, and with this occurs the frequent dull-
ness or headache indicative of obstructed portal circulation. The patient is generally of se-
dentary habits, and, having a good appetite, is disposed to eat a great deal more than he can
digest. The first step in treatment then is to restrict his diet or to increase his amount of
daily exercise, or, if possible, to do both. It is usually much easier for the physician to les-
sen the food than to increase the exercise of the average patient ; and as there is no particular
kind of food to which the pruritus or eczema of the anus can be attributed, I have followed
the plan of prescribing but one meal daily, at which the patient can eat whatever he likes
and as much as he likes. In place of the other two customary meals the patient may be al-
lowed a glass of milk, if this does not produce a coated tongue and increase the constipation,
or, what is usually better for him, a cup or two of hot water with one or two graham crackers.
This plan of dieting gives the stomach and other digestive organs the rest which they usually
need, and in obstinate itching of the anus mil often render the use of local applications quite
unnecessary. When, however, there is much thickening of the sldn about the anus, some
soothing local remedy may be simultaneously employed. Innumerable have been the appli-
cations recommended for this purpose, but the one which has seemed to me to do the most
good in the largest number of cases is the officinal chlorofonn liniment. In many patients
of a nervous temperament the use of tobacco, even in moderation, \vill serve to aggravate the
affection, and hence in every obstinate case, it is well to proscribe this, together with indul-
gence in tea, coffee and alcoholic stimulants.
(72)
DERMATITIS EXFOLIATIVA.
lOTTPt, E. BIEfl
ECZEMA.
In eczema of the scrotum a similar plan of diet will prove beneficial, though perhaps to
a less extent than in eczema of the anus. Local treatment will naturally vary in accordance
with the grade of inflammation and condition of the skin. When there is a moist surface or
numerous excoriations the most cooling application is the salicylic and bismuth ointment
already mentioned in connection with infantile eczema. When the skin is thickened, dry
and harsh a napthol ointment of from three to five per cent, strength Avill lessen the itching
and gradually soften the skin. In very chronic cases the compound chrysarobin pigment
may be used. This occasions considerable smarting for five or ten minutes after its applica-
tion, but it vdll usually secure to the patient a quiet sleep at night, and if frequently applied
will soon restore the skin to its normal condition.
In severe eczema of the vulva or penis an examination of the urine should be made from
time to time, as a diabetic condition is frequently the underlying cause of the eruption, which
will continue to resist all treatment until by a judicious modification of the diet the sxagar
disappears or is reduced to a minimum in the urine.
ECZEMA OF THE LEGS. Eczema of the lower portion of the legs is common in mid-
dle life and old age. It is usually of long standing, and requires stimulation. When the
eruption is dry, as in the erythematous and papular forms, the skin is simply reddened,
harsh, itchy, and more or less excoriated. Daily frictions with green soap will soften the
skin and relieve the itching. After using the soap, the legs should be carefully dried, and a
slightly astringent ointment applied. In the squamous form, the soap frictions wiU remove
the scales and often cause an exuding surface to appear. This temporary aggravation, how-
ever, by stimulating the flow of the blood through the part and promoting absorption, will
speedily reduce the thickening of the skin. In the ichorous form of eczema (weU shown in
the plate of Eczema cruris), and in the squamous form when there is any tendency to a dis-
charge, the application of vulcanized rubber cloth is one of the best plans of treatment. It
cleanses and cools the surface, promotes a copious flow of serum, and quickly lessens pain and
swelling. The cloth should envelop the leg with the rubber surface next to the skin, and be
held in position by a roller bandage. When the ankle is affected, the cloth may be gored or
cut so as to fit smoothly. The rubber bandages, to be described later in the treatment of
varicose conditions, are sometimes preferable, though more likely to irritate the healthy skin.
When the leg has returned to its normal size, and the exudation has nearly ceased, the rub-
ber is no longer of service, and the cure may be completed by applying the nitrate of mer-
cury ointmerit, one or two parts, to the oxide of zinc ointment, eight or nine parts. When
the skin is infiltrated, itchy and scaly, but only to a slight extent, the preparations of tar
can be advantageously employed. Where there is an exuding surface the use of tar is contra-
indicated.
The permanent dilatation of veins to which the term varicose is applied begins usually
in early or middle life, and affects chiefly the internal saphenous and its branches. Tho
enlarged vein may be simply distended, or it may be hypertrophied, and either form a tumor
by doubling on itself, or run a serpentine course for a short distance. About the ankle and
(73)
DISEASES OF THE SKIN— INFLAMMATORY.
on the dorsa] surface of the foot, it is common to find the venous twigs dilated, and appear-
ing as numerous purplish blue dots or streaks. The cause of varicose veins is not always
apparent, although ill health, standing occupations, pregnancy, tight garters, etc., doubtless
exert an influence in their production. The result of their presence, however, rather than
their causes, renders them of importance from a dermatological standpoint. In many
persons varicose veins of the lower extremities exist for years without producing any eifect
upon the skin, or even inducing any feeling of discomfort. Given, however, a tendency
to eczema in such a case, and it wUl not be long before some external irritation will
provoke an eruption which will prove rebellious to ordinary treatment, on account of the
oedema and infiltration of the skin, which in time becomes associated mth varicose veins
of the leg.
Treatment. The treatment of varicose eczema involves the ordinary therapeutic meas-
ures adapted to the cure of the disease, with the addition of a support for the enlarged veins.
So long as the limb is allowed to swell daily from pressure or a column of blood, so long will
lotions and ointments fail to effect a cure. If the limb cannot be maintained in a horizontal
position (and exercise is as desirable in many cases as it is unavoidable), some form of bandage
or elastic stocking is required. The ordinary roller, if smoothly applied, answers a two-fold
purpose in compressing the limb and keeping the dressings in place. But rarely do we find
a patient who can make the reverse turns properly, and a bandage twisted around the leg and
drawn tight to keep it from sliding down will do more harm than good A flannel roller is
preferable to one made of cotton cloth, on account of its greater elasticitj^ and softness, and
when applied moist it will produce a tolerably firm compression of the leg. As for the elas-
tic stockings in the market it may be said that the cheap ones are useless, while the good
ones are too expensive for a large class of patients. The rubber bandage introduced by Dr.
Martin has of late become widely known and deservedly popular. It not only supports the
dilated veins and thus tends to remove a cause of the eruption, but by its local action it ma-
cerates the epidermis, and facilitates the escape of serum confined in the skin and subcuta-
neous tissue. By its elasticity it exerts a constant pressure on the leg, and induces a rapid
absorption of the products of inflammation. It is, in fact, a happy combination of the im-
permeable rubber dressing and the elastic stocking. It can be applied by any patient of
average intelligence, as no reverse turns are needed ; it can be tightened or loosened with
ease, and, unlike the ordinary roller, which speedily becomes loose, it maintains its pressure
even when the leg decreases in size by subsidence of the oedema. The rubber bandage should
be applied in the morning before the patient gets out of bed. At night, after its removal,
both leg and bandage should be washed and carefully dried. The bandage may now be re-
applied, or if the infiltration has nearly disappeared, and especially if the skin is much irri-
tated, it is better to dress the leg with an emoUient ointment and to wait until morning before
re-applying the bandage. In cases where the bandage is applied for an eczema of the ankle
or lower part of the leg, the healthy skin above may become irritated. This can be prevented
liy dusting the sound skin night and morning with powder of starch, oxide of zinc or bis-
(74)
PITYBIASIS.
muth, but it indicates an eczematons tendency on the part of the patient and suggests greater
reliance on internal medication.
PITYRIASIS.
Pityriasis is a mild affection of the skin, in which a very slight redness and a mealy or
branny desquamation are the chief features. There may be a triiling amount of infiltration
of the skin when the affection is well marked, and a sensation of heat or pruritus ; but
ordinarily the skin is not thickened in any noticeable degree, and no especial discomfort is
experienced. The scales are small, white, not imbricated, as in psoriasis, and very readily
removed by friction. When rubbed or washed away, they foi-m again very quickly. The
disease occurs in patches of variable size, the borders of which shade off into the surround-
ing healthy skin. It is most frequently met with upon the scalp and face, but may occur
upon the neck and covered portions of the body. Upon the scalp it constitutes a dry form
of dandriff in which the scales are not fatty in character, as in seborrhoea capitis, but are
composed wholly of fine epidermic flakes. It is the kind of dandriff in which the scales do
not adhere to the scalp, but fall copiously whenever the hair is brushed, and accumulate
upon the shoulders. It is usually the result of a pre-existing erythematous condition of the
scalp, is very chronic in character, and usually indicative of a lowered vitality of the scalp,
if not a condition of general nervous debility. Care, anxiety, or dissipation wUl often pro-
duce an immediate effect in augmenting the amount of desquamation and the falling of the
hair, which, in time, becomes an inevitable concomitant of dandriff. The eye-brows and
beard are often simultaneously affected with the scalp.
Upon the face, pityriasis is most apt to occur in the winter season, and after exposure
to harsh winds. Those subject to the affection are usually found to have a pretematurally
dry skin, and in infants and young children an eczematous tendency is commonly present.
When caused or aggravated by external influences, the eruption may only last for a week
or two, but in many cases it is quite persistent.
Diagnosis. The diagnosis of pityriasis from a mUd case of erythematous or squamous
eczema, is not readily made, and indeed many writers do not admit that pityriasis is a dis-
tinct disease. In many cases pityriasis gradually merges into eczema, but when there is
merely a rosy colored patch of skin, covered with fine white scales, the clinical appearance
is quite different from eczema, and the infiltration or thickening of the skin, the cracking of
the epidermis with a tendency to moisture, and the annoying pruritus, which are essential
elements of the latter affection, are never met with in the former.
Psoriasis sometimes appears in patches of a pinkish color, and with very little scaling,
but in such cases the marginate border of the patches, their characteristic localization, and
their symmetrical development would prevent an error in diagnosis.
Trichophjiiosis of non-hairy parts sometimes presents an appearance very similar to that
of pityriasis, as far as color and desquamation are concerned, but the outline of the paiches
(76)
DISEASES OF TEE SKIN.— INFLAMMATORY.
is quite diflferent in the two affections. In ordinary pityriasis the patches are not usually
circular, and have no well defined margin, while in ring-worm these are characteristic
features.
Seborrhoea is the affection with which pityriasis is most apt to be confounded, and as
has been already stated, when these affections occur upon the scalp, a strict differential
diagnosis cannot always be made. Upon non-hairy parts the patches of pityriasis feel dry
and harsh, while those of seborrhoea feel greasy to the touch, and may lea ve a trace of oU
upon the finger which is passed over the affected skin.
TitEATMENT. The iuunction of any fatty substance will suffice to cure many cases of
pityriasis, but a slightly stimulating ointment, such as the following, wiU usually act more
rapidly.
9. Ointment of Ammouiated Mercury,
Ointment of Rose Water, - equal parts.
M.
For pityriasis capitis this ointment may be rubbed into the scalp daily upon the tip of
the finger, and the head shampooed with the tincture of green soap once or twice a week.
If the greasy nature of the application renders it objectionable, the following lotion may be
employed with benefit.
9. Chloral, 6 parts.
Tincture of Veratrum Album. - - 10 *'
Perfumed Spirit, ... to 100 "
M.
In pityriasis of the face, the effect of water frequently applied, and exposure to cold
winds, are apt to be as irritating as in cases of eczema. It is therefore advisable to apply
some soothing ointment or lotion immediately after washing, and always before going into the
open air. The following lotion will be found of value to prevent the skin from becoming
rough and chapping.
9. Borax, 3 parts.
Glycerine, 6 "
Rose Water, .... to 100 "
M.
DERMATITIS EXFOLIATIVA.
Synonym — Pityriasis rubra.
Exfoliative dermatitis is a comprehensive term which is now applied to certain rare cases
of skin disease, which are characterized by intense redness of the skin and desquamation of
the epideimis in large flakes. It probably includes one or two distinct affections, but in the
present state of our knowledge it is hardly possible to separate them. While some cases
(76)
T«. .MT 1889
PSORIASIS NUMMULATA
AMlO'YPfc, £. BitRStADI
DERMA TIT IS EXFOLIA TI YA .
have appeared in an acute form, the majority of those described under the title pity liu si ■>
rubra, or dermatitis exfoliativa, have been extremely clironic in their course, evincing a ten-
dency to recurrent exacerbations or relapses, and frequently terminating in death from
marasmus or exhaustion. The disease has been limited in a few cases to a portion of the
body, but as a rule, the hyperaemia and exfoliation are general, and not the smallest portion
of skin remains unaffected.
In those cases which have been observed in the incipient stage of the disease extensive
reddened patches covered with a fine desquamation have appeared in the axillary inguinal and
popliteal regions. These have spread rapidly until they have invested the entire sui'face of
the skin. At this stage the eruption is very striking in appearance. The skin is of a rather
bright red color, with perhaps a duller or somewhat livid hue upon the extremities, and the
local temperature is elevated. Pressure of the finger caused the hypersemia to disappear,
leaving the skin of a yellowish tinge, and pinching up a fold between the thumb and finger
shows that there is very little, if indeed any, infiltration and thickening. The desquamation
which is persistent and abundant is made up of thin flakes which curl up at the margin,
while adherent in the centre to the underlying skin. These flakes are usually of large size,
and when forcibly removed leave a smooth, glazed, or a slightly moist surface.
The patient experiences a moderate amount of pruritus, in some cases, and invariably
complains of a sensation of chniLness. This condition may persist without any notable
change for one or two years. In time the skin begins to appear tightly drawn, as though it
were too small for the body. Fissures and ulceration are now liable to occur. The expres-
sion of the countenance becomes greatly altered from the resulting ectropion of the lids and
lessened mobUity of the lips, and the fingers and larger joints are usually partially flexed.
The hair and nails lose their lustre, become friable, and are often lost. The general health
fails, and without the best of care and nursing, the patient falls into a pitiable condition.
Diagnosis. The affection which bears the closest resemblance to exfoliative dennatitis
is a chronic universal eczema of an erythematous or squamous type. In this affection, how-
ever, there is apt to be considerable thickening of the skin, a most annoying jDruritus and at
some time and in some locality a moist surface, ■with the peculiar mucilaginous character of
a typical eczematous discharge. At the same time, it must be borne in mind that in some
cases of exfoliative dermatitis we may have a slight thickening of the skin, more or less
pruritus, and a thin serous moisture of the skin when the flakes of epidennis are removed.
Psoriasis universalis might be mistaken for exfoliative dermatitis, but the similarity is
by no means so striking as in the case of eczema. Psoriasis rarely, if ever, covers every inch
of skin, biit usually leaves some small portions in a normal condition. It is a pei'fectly diy
eruption, and is not associated with any marked impaiiment of the general health. The
scales may be thick and horny but are never seen in large papery flakes, and the eruption,
however extensive or chronic, is always disposed to yield to a judicious local treatment.
Pemphigus foliaceus may, in certain cases, and at certain times, be indistinguishabh*
from exfoliative dermatitis. The occurrence of flattened and imperfectly formed bullae i:i
(")
DISEASES OF TEE SKIN— INFLAMMATORY.
the former affection, is the only distinctive feature. The present tendency of dermatologi-
cal writers is to class these two affections together, and I may quote an opinion expressed
nearly ten years ago in connection with the report of a case of pityriasis rubra. (Archives
of Dermatology.) "In the extensive exfoliation of cuticle, in the serous exudation which
in the one case imparts to the skin a peculiar moisture, and in the other case Ufts the epi-
dermis into bullae, in the marasmus of the latter stage, and in the slow recovery if not the
fatal termination of either disease, we observe a striking similarity, and I venture to say that
a deeper insight into the etiology and nature of skin disease will yet reveal an intimate con-
nection between these two affections." Hyde, who, describing pityriasis rubra and pem-
phigus foliaceus as two forms of exfoliative dermatitis, writes as follows : " If it be objected
that pityriasis rubra and pemphigus foliaceus should be disassociated because the former is a
dry and non-discharging disease, and the latter a moist and exuding affection, characterized
always at first and often at last by the occurrence of blebs, the answer is sufficiently ami^le.
The same arguments precisely which demonstrate the identity of erythematous, papular and
vesicular eczema, will Indissolubly connect the two affections under consideration."
Tkeatment. Little can be done in most cases of exfoliative dermatitis which will influ-
ence the course of the disease. Arsenic has been thoroughly tried and found wanting. Fresh
air, nutritious food and tonics will prove of some value, and the fi'equent inunction of linsted
oil in large quantity will keep the skin in a comparatively comfortable condition. Tilbi/ry
Fox was a strong advocate of the value of alkaline diuretics given with a view to relieve the
cutaneous congestion by stimulating the kidneys to increased action. In -one case, I have
noted a remarkably beneficial effect follow the administration of di'achm doses of acetato of
potassium, three times daily. At best, the prognosis in this affection is extremely grave.
PSORIASIS.
Synonyms — Lepra — Alphas — Dry tetter.
This very common affection consists in circumscribed patches of red and thickened skin,
covered usually ^vith whitish or yellowish- white scales. The patches may be isolated or con-
fluent. In the former case they vary in size from a pin-head to a saucer, and are circular in
form. In the latter case they give rise to large irregular patches, with scolloped borders, and
frequently with inclosed areas of normal or slightly pigmented skin. In some cases the
entire body and especially the trunk may be affected, and appear reddened, thickened, and
more or less scaly. The patches always begin in the form of small red papules, surmounted
by a thin scale. These may be scattered abundantly over the body, and show little or no
tendency to increase in size (P. punctata). They are more apt, however, to assume the size
of a cent or quarter-dollar, and when numerous and aggregated they appear as though a
handful of thin mortar had been spattered over the skin (P. guttata). In a small number of
(^ases the patches are few and large, and appear like sUver coins of large size (P. nummulata).
Generally the patches tend to coalesce as they increase in size, and lose their circular outline
(78)
PSORIASIS ANNULATA
TOTrPt, E. BlEBSTAOT
PSORIASIS.
(P. diffusa). In nearly all cases the central portion of the patch is the first to disappear, and
in consequence scaly rings are produced (P. annulata) and in rare instances crescentic and
seiiaentine lines (P. gyrata). The scales of psoriasis are imbricated, and in most cases easily
removed. In appearance they have been compared to sUver and to mother of pearl. Their
thickness is usually in proportion to the amount of infiltration of the subjacent sldn. In
diffused patches they are often branny in character, whUe in chronic cases they become thick
and hard, like plates of armor. The extensor surfaces of the extremities, the back and the
scalp, are the favorite sites of the affection. Upon the elbows and knees and along the fron-
tal margin of the scalp it occurs with the greatest frequence, although it is not invariably
present upon these parts.
Of the etiology of psoriasis very little is knoAvn. It occurs imder the greatest variety of
conditions and shows little or no partiality for any climate, race, age or sex. Its relation-
ship to syphilis and to tuberculosis has been claimed by some, but never satisfactorily demon-
strated. Lang has recently attempted to prove its parasitic character. It is not contao-ious
but in very many families the hereditary transmission of the disease or of a tendency to it
is quite manifest. When a tendency to psoriasis exists clinical observation shows that preo--
nancy, lactation, or whatever reduces vitality tends to provoke the eruption, and even exter-
nal irritation or injury to the skin Avill often determine the localization of the lesions. WhUe
some \vriters connect psoriasis mth a dartrous or rheumic diathesis, others regard it as a
purely local disease. The symmetrical nature of the eruption which is almost invariably one
of the most striking features would seem to indicate that the disease was constitutional and
either dependent upon some dyscrasia or lesion of the nerve centres which control the for-
mation of the homy stratum of the epidermis. The majority of psoriatic patients seem aa
strong and hearty as the average of mortals, and if not in perfect health, they at least be-
lieve themselves to be so.
Diagnosis. The diagnosis of psoriasis is generally easy, especially in typical cases. It
must be constantly borne in mind, however, that the eruption may be in its declining stage
or modified by previous treatment, in which case it differs greatly in appearance from the
eruption when seen at its height and before treatment. If a psoriatic patient is stripped suf-
ficiently to reveal the greater portion of the eruption, a diagnosis can readily be made by
observing the characteristic configuration of the patches even when viewed at a considerable
distance. When the eruption is seen in its incipient stage, and only a few scaly points or
drops are present, a diagnosis can often be arrived at by observing the ease with which the
scale can be removed by the finger naU, and the bleeding corium which is exposed beneath it.
Too much stress, however, is often laid upon this point, as in some cases of eczema, where
tbe eruption is recent and accompanied by sUght scaling and little or- no infiltration of the
true skin, the finger naU may remove the epidermis as readily as in psoriasis, and a number
of bleeding points will be seen springing from the lacerated papillae. If the condition of the
eruption, together with its location, does not settle the diagnosis, the history of the case will
generally furnish the necessary clue. Its occurrence at certain seasons of the year, and its
(79)
DISEASES OF THE SKIN.— INFLAMMATORY.
partial or complete disappearance at others, its absolute and persistent dryness, aud its ten-
dency to relapse after being apparently cored, are features of the case which point only to
psoriasis.
The papulo-squamous syphilide is the one eruption above all others which may bear a close
resemblance to a typical psoriasis, and in certain cases it is very difficult, if not impossible,
to make a diagnosis of the eruption without taking into consideration the history and con-
comitant symptoms. If the eruption is chronic and has disappeared and reappeared from
year to year it is undoubtedly psoriatic, while on the other hand, if it has developed recently
and extensively, and is associated with other unmistakeable symptoms of syphilis in its
early stage, the syphilitic nature of the eruption is highly probable. It is commonly stated
that psoriasis affects the extensor aspect of the extremities, while the scaling papular syphi-
lide is seen chiefly upon the flexor surface. Too much stress must not be laid upon this
point, for exceptions to the rule in either disease are common. Nor is the presence or absence
of itching a trustworthy point of differential diagnosis, for in certain cases of psoriasis there
may be very little or no itching, while in nearly aU squamous syphilides the patient will con-
fess to a slight pruritus if questioned in regard to the matter.
The color of the lesions in the two diseases is practically the same and is never charac-
teristic. The scaling is usually more abundant upon the psoriatic guttje, while the infiltra-
tion of the skin is more marked in the sj-T^hilitic lesions.
Eczema, in its squamous form may be mistaken for psoriasis when, as occasionally hap-
pens, it occurs in orbicular patches with a circumscribed border. The limited extent of the
eruption, its non-symmetrical location, together with the pruritus and a tendency to become
moist and form crusts instead of scales when the surface is violently rubbed, are points which
will usually lead to a correct diagnosis.
Treatmext. The treatment of a case of psoriasis is simple as far as regards the removal
of the eruption. It is a much more difficult matter to prevent its return. In nearly every case
there is undoubtedly a morbid condition of the economy, an ill-defined something, deeper
than the scaly patches. Some call this the disease, and regard the cutaneous affection as a
mere symptom. Others apply the term psoriasis solely to the cutaneous lesions, and look upon
internal morbid conditions as predisposing causes. The supporters of the diathetic nature of
psoriasis assert that local measures cannot cure the disease, while others claim that when the
skin is restored to its normal condition the disease is cured for the time being, although the
imperfectly understood causes still existing may induce its return. This is a mere quibble.
Local applications will restore the skin to its normal state in nearly all cases, while in many
it is extremely difficult to prevent relapses, even with internal treatment. Most cases of psoria-
sis demand a combination of internal and external treatment, but where the general health is
good, local treatment is of chief importance. In estimating the value of any local applica-
tion or plan of treatment it must always be borne in mind that psoriasis is rarely stationary,
but tends to improve or to completely disappear at certain seasons of the year. The value
of a remedy can only be determined, therefore, by observation of its effect in a number of cases.
(80)
PSORIASIS DIFFUSA
Tft, i. BltRSTAOr
PSORIASIS.
In the local treatment of psoriasis, our aim should be three-fold, viz., to soothe the bk;;i.
to soften and remove the scales, and to promote absorption of the infiltrated patches. In no
disease of the skin is bathing of more importance than in psoriasis. The Turkish bath ful-
fils each of the three indications above mentioned, and often does more to improve the general
health of the patient than the administration of drugs. When the psoriatic patches are red
itchy and irritable, as they frequently are, the mistake is too often made of giving arsenic in
ternally, and applying stimulating applications to the diseased skin. It is far better, in such
cases, to prescribe a daily bath with inunction of cosmoline, or vaseline, until the acute
inflammatory symptoms have subsided. Intense itching may be allayed by means of a lotion
of carbolic acid (10-15 per cent.) in glycerine. The irritability of the patches being subdued
soap frictions may be added to the bath to remove the accumulated epidermis, although, when
the scales are but moderately thick, they are quickly softened and removed by the stimula-
ting application employed to lessen the infiltration of the skin. When in inveterate cases
the scales ai-e like plates of horny armor, they need to be softened by painting them with
acetic acid and scraping them off with a curette, or by enveloping the limb, or even the body,
in a close-fitting garment of vulcanized rubber cloth, worn with the smooth side next to the
skin. To the red and thickened patches now exposed may be applied one of numerous
stimulating remedies of variable strength. Tar has been most extensively employed, and its
most convenient form, the oil of cade, is a serviceable application.
But the use of tar in psoriasis has been completely superseded within the past ten years
by the introduction of chrysarobin. This remedy has grown steadily in favor with the pro-
fession until it has attained a recognition as one of the foremost agents in the local treatment
of various chronic diseases of the skin.
For several years after the introduction of this drug (under the name of chrysophanic
acid) it was used in the form of an ointment of varying strength, and scarcely any one who
tested its value failed to be struck by its peculiar effect upon the sound skin, and surprised
at its beneficial action upon diseased patches. But there were objectionable features con-
nected with its use in the form of an ointment, which could not be overlooked, and these were
often so marked that they served in many instances to counterbalance the value of the reme-
dy. In all cases the healthy skin became temporarily discolored, which was not a very
serious matter, but at the same time the underclothing of the patient became permanently
stained and usually ruined by a single application of the ointment. Furthermore, the effect
of the remedy was found to be somewhat different in degree upon different skins, and in
some cases a violent dermatitis was occasioned even by the use of mild ointment, and this
often proved to be worse than the disease for which it was applied. Under these circum.
stances many were led to give up the use of the remedy, while a few were prompted to seek
a means which would obviate its objectionable qualities without impairing its efficacy in any
marked degree. The efforts of the latter have been finally cro\vned with success, and it may
be now asserted that the local effect of chrysarobin can be obtained without danger of its ex
citing a dermatitis of the healthy skin or causing a discoloration of the patient's clothing.
(81)
DISEASES OF TEE SKIN.— INFLAMMATORY.
Various experimenters, both here and in Europe, have adopted different means to obtain thia
result, untU all have arrived at the conclusion that the chrysarobin must be incorporated in
some elastic and adhesive varnish.
My first attempts to solve the question led me to the employment of a paste made by
mixing the chysarobin powder with a quantity of water. This was applied to the affected
Bkin and covered with flexible collodion, or a little absorbent cotton moistened with the white
of an egg, or a piece of gutta percha tissue, the edges of which were glued to the skin by
means of chloroform. This plan was effective but troublesome. I also tried chrysarobin
sprinkled on plaster, and other devices which I need not mention. Finally I resorted to a
mixture of chrysarobin and collodion, which made a neater application, though it lessened
somewhat the activity of the remedy. About a year or more ago, having observed the pe-
culiar effect of salicylic acid in softening corns and epidermic tissue in the form of scales, it
occurred to me to combine this remedy with the chrysarobin in coUodion, and my subsequent
use of this pigment or varnish in both private and hospital practice has convinced me that
this combination greatly enhances the value of the simple chrysarobin in collodion. It ap-
parently causes it to adhere more firmly to the skin, and to produce a more marked effect
upon the diseased patches. The formula which I have employed with the greatest satisfac-
tion, and which at the New York Skin and Cancer Hospital is known as the " Pigmentum
Chrysarobini Compositum," is the following :
9- Chrysarobin, 10 parts.
Salicylic Acid, 10 "
Ether, 15 "
Flexible CoUodion, to - - - 100 "
M.
In Europe the mixture of chrysarobin and coUodion has been recommended by Sese-
mann, whUe gelatine has been employed as a vehicle for the chrysarobin by Unna and Pick.
Recently Auspitz has recommended the use of chrysarobin in a solution of gutta-percha. I
have used this application in the treatment of a number of cases of psoriasis and it is certainly
an elegant and efiicacious one. The chloroform has the advantage over ether in dissolving a
trifle more of the chrysarobia, but the efficacy of the application would be increased, in my
opinion, by the addition of ten per cent, of the salicylic acid, for the reasons which I have
already stated. The use of the liquor gutta-perchse, U. S. P., as a vehicle for the chrysaro-
bin and saUcyUc acid is weU adapted to use in private practice, but the use of coUodion as in
the formula given above is more desirable in hospital and dispensary practice, as the cost of
the latter pigment is one-half that of the former. Of course, it must be carefuUy kept in a
well-corked and preferably in a wide-mouthed bottle. It can be applied to the diseased skin
by means of a smaU stiff paint brush, and should the pigment become slightly thick at any
time, it can be made as thin as desirable by the addition of a small quantity of ether. In
some cases it is advisable to apply the remedy in the form of a thick varnish, whUe in other
cases, where only a sUght effect is required, it is better to apply only a thin coating. For
(82)
PSORIASIS MANUM
PSORIASIS PEDUM.
PSORIASIS.
this purpose a larger quantity of ether should be used in the formula given above. Occa-
sionally the pigment produces temporarily a stinging sensation, but this is scarcely worthy
of mention when we consider the perfect relief from itching which frequently ensues. The
yellow coating upon the skin dries very quickly, and if not disturbed by unusual friction or
bathing, it remains upon the skin without incommoding the patient in the slightest degree
for sevei-al days. It then begins to fall off, and usually requires a renewal. When severe
pruritus has been present and is relieved, as is commonly the case upon application of the
pigment, a second application should be made as soon as the coating begins to crack or peel,
as at this stage the prm-itus is very apt to return.
In the local treatment of psoriasis chrysarobin is without doubt a truly great remedy.
No one can fail to appreciate and be thankful for the progress of medical science who con
siders how, less than ten years ago, psoriatic jjatients were persistently smeared ^vith tar, and
often smeared in vain, and appreciates the fact that now it is a comparatively simple matter
to cause a speedy disappearance of the scaly patches in nearly every case. And it is another
step in advance which has superseded the ointment of chrysarobin by applications of the
remedy which do not ruin the clothing and inflame the healthy skin. In the treatment of
psoriasis the compound chrysarobin pigment is, in my opinion, the best application which can
be employed in at least ninety per cent, of cases, and may be applied to all parts of the body
with the exception of the scalp and face. Here, the use of ammoniated mercury oiatment,
which is of little value when applied to the trunk and extremities, will generally suffice to
remove the eruption in a very short time.
Of the internal treatment of psoriasis but little need be said. While in no other affec-
tion of the skin has such a wonderful improvement in the method of local treatment taken
place of late, our knowledge of the nature and internal treatment of psoriasis has not ma-
terially advanced. I have tried antimony, carbonate of ammonia, chrysarobin, and a few
other drugs recommended for internal use in this disease, but without observing any marked
benefit.
Psoriatic patients are not usually in need of tonics. Some errors in digestion may be
discovered and require to be corrected. An alkaline plan of treatment may be called for by
the association of the disease with a rheumatic or gouty habit, and should be our chief reli-
ance whenever the patches are hypersemic and irritable. The acetate or citrate of potassium
may be given in from one to two gram doses (fifteen to thirty grains), in a half glass of water,
a short time before meals. In chronic cases arsenic is an old, a well-tested and an efficient
remedy. It may be given in the form of the liq. potassii arsenitis, the liq. arsenici chloridi,
or the so-called Asiatic pills converted into a powder (Piffard).
]pl. Arsenious Acid, .... 2 parts.
Black Pepper, - - - - 18 "
Sugar of MUk, to - - - - 100 "
M.
Prom one to five grains of this powder may be taken with each meal, being sprinkled on
(83)
DISEASES OF THE SKIN— INFLAMMATORY.
the food in the place of salt, if agreeable to the patient. Before the effect of the arsenic
upon the eruption in any given case can be observed, the patches can be usually removed by
a resort to the local treatment already described, but the drug will often prove useful in pre-
venting a relapse.
MILIARIA.
Synonyms — Lichen Tropicus — Lichen jSstivtis — Prickly Heat.
Miliaria is a fine papular or papulo-vesicular eruption, which is very common, not only
in the tropics but in temperate climates, especially during the excessive heat of midsummer.
The lesions consist of minute conical elevations of the skin, closely aggregated, and of a
bright red hue. When fully developed, the summit of each lesion presents a whitish appear-
ance from the effusion of the minutest drop of serum. The eruption is generally limited to
a portion of the trunk, but may appear upon the face, neck and extremities. Only in excep-
tional instances is the eruption general. The skin is usually bathed in perspiration, and
there is always present a peculiarly annoying sensation which has given to the affection its
common name of "prickly heat." The adjectives alba and rubra are sometimes employed
in connection with the term Miliaria, to indicate the degree of congestion of the skin and
resulting color of the eruption.
The cause of Miliaria is to be found in a combination of agencies, which conspire to pro-
duce an undue congestion of the skin. Hot weathei', excess of clothing, and vigorous exer-
cise commonly evoke the eruption. It is most common among children, especially such as
are debilitated and poorly cared for. Among adults it is not infrequent, and is most apt to
affect those whose vitality is lowered by dissipation of various kinds. The free use of alco-
holic stimulants in hot weather often induces the eruption, and aggravates it when resulting
from other causes. Miliaria is especially common among those who have a fair complexion
and thin delicate skin.
Diagnosis. The eruption is generally recognized without difficulty when existing alone,
but as not infrequently occurs in connection with a papular eczema, a mistake in diagnosis
may now and then occur. The larger size of the papules in eczema, their more scattered
distribution, and the itching which attends them and results in the excoriation of their sum-
mits, will serve as a distinctive feature. Chicken pox and German measles, occurring in hot
weather, have been mistaken for prickly heat, but no careful physician ought to be led into
such an error.
Treatment. The chief aim in the treatment of Miliaria is to keep the skin as cool as
possible. To accomplish this end, the exciting causes already mentioned must be avoided.
Work and worry should be reduced to a minimum, and one or more cool baths taken daily.
Rest, light clothing, and frequent draughts of lemonade, or some other cooling beverage^
will speedily check the eruption in the case of adults. In children the affection is apt to be
more troublesome, and sometimes persists for weeks in a more or less aggravated form. The
(84)
PITYRIASIS CIRCINATA.
PLANUS
LICHEN PLANUS.
remedies which I have generally advised, and found nsefnl, are two which are commonly
found in every household, viz : cream of tartar internally, and starch powder locally. A
teaspoonful of the cream of tartar may be stirred up in a glass of water, and a few swallows
taken every half hour. Locally, an absorbent powder will prove far more agreeable than an
ointment.
LICHEN PLANUS.
Synonym — Lichen Ruber Planus.
Lichen is a name which was applied by the older dermatologists to all diseases of the
skin, the lesions of which consist of persistent papules. Several varieties of lichen are
described, but as a more careful study of the natural history of skin diseases has shown that
these are not varieties of one disease, but papular stages or forms of widely different dis-
eases, most of them have become obsolete as forms of lichen, being known at present under
different and more appropriate names. Lichen simplex, according to many writers, is noth-
ing more nor less than a papular form of eczema (See plate of E. papulosum). Lichen lividus
is Purpura papulosa ; Lichen urticatus is Urticaria papulosa ; while Lichen syphiliticus is
Syphiloderma papulosum, a name expressing the nature of the disease, which is, of course,
of vastly more importance than the form and appearance of cutaneous lesion. There still
occur, however, papular eruptions which cannot be considered as mere papular foi-ms of any
disease otherwise named, and to such the term "Lichen " is justly applied.
Lichen planus consists in an eruption of peculiar papules, which may be disseminated
or aggregated, and either occupy a limited region, or extend over a large extent of the general
surface of the skin. The chief peculiarity of the papules, and one which gives rise to the
name, is their flattened summit. They are but slightly elevated, and though rising abruptly
from the healthy skin, they do not possess the conical or rounded summit of ordinary pap-
ules, but appear as though they had been shaved off or pressed dowTi. The summit is smooth
and horny, and sometimes presents a glistening appearance. Usually a punctate depression,
or umbilication, is seen in the centre of this flattened surface. The base of the papule is
often angular in its outline. Li size, the papules vary greatly in different cases, and slightly
upon different portions of the body. They are usually of the size of a pin's head, biit may
be considerably larger. As in the case of the papular syphilide, both a miliary and a lentic-
ular form of Lichen planus may occur. The color is a pale yellowish red when the papules
are small, and ' ' dull crimson," or violaceous, when they are larger, the centre being somewhat
lighter than the rim of the papule. The papules may be regularly disseminated over a given
surface, or strewn in groups, even when not coalescing. The papules, when once developed,
persist as such, never evincing the slightest tendency to vesiculation or pustulation. They
do not increase in size, and patches are formed by the springing up of new papules amonir
the older ones. The isolated papules are not scaly ; but when they become aggregated, the}"
lose their peculiarities of form and appearance, and irregular patches of thickened skin result,
(85)
DISEASES OF TEE SKIN.— INFLAMMATORY.
with a dry, haxsh, homy surface, which to the touch feels like a file, or even a nutmeg
grater. At the border of such a patch the typical papules may sometimes be observed. The
disease is attended with a certain amount of itching in every case, and the utmost distress is
sometimes occasioned by this symptom. It develops with variable rapidity, requiring but a
few weeks, in some cases, to produce an extensive eruption. Limited patches, on the other
hand, often remain for months without change. The disease is chronic in most cases, and
shows little disposition to yield readily to treatment. The anterior surface of the fore-arm
and wrist is the most favorite locality.
The cause of the affection is obscure. It is certain, however, that those affected by i1
are far from being in perfect health. The debilitated condition of the system in this disease
is more noticeable than in eczema, and far more so than in psoriasis. The eruption may
occur in either sex, in the young as well as the old, and upon almost any portion of the
body. It occurs far more frequently in females, according to my experience, and usually
in middle life.
Diagnosis. The diagnosis of Lichen planus is not generally difficult for one who has
had the opportunity of seeing a well-marked case of the affection. But, as the disease is com-
paratively rare, the reader may be caUed upon to diagnose and treat a case without this ad-
vantage. If the case is typical it will correspond with the description given, and with that
of no other disease. The papular syphilide ought not to be mistaken for it, owing to the
regular distribution of papules over the body, and the absence of itching in the former affec-
tion. The papules of eczema are itchy, often affect a limited region, may be both disseminate
and grouped, and resemble Lichen planus at first glance. They are brighter in color, how-
ever, conical in form, and never present the angular base, flattened summit, and central de-
pression, which characterize the papules of the latter affection.
Treatment. The general health in many cases being impaired in a greater or less degree,
the strictest attention should be paid to dietary or hygienic measures. The digestive organs
must be kept in as normal a condition as possible, and the most nourishing and easily digested
food prescribed. Of internal remedies, the alkaline diuretics seem to be productive of the
best results by reetiving the cutaneous congestion. In many cases of this disease, and indeed
in any case of chronic skin disease where an imperfect oxygenation of the blood exists, it is
advisable to administer a gram (fifteen grains) or more of chlorate of potassium, fifteen min-
utes after each meal, and twenty drops of dilute nitric acid in water, fifteen minutes later.
Wilson recommends quinine, nitro-muriatic acid and chalybeates.
Unna treats lichen planus mainly by the application of the following ointment.
9 Corrosive sublimate, - - - - 1 part.
Carbolic Acid, 20 part».
Benzoated zinc ointment to - - 600 "
M.
This is to be rubbed into the affected skin every night and morning, the patient remain-
ing in bed. A cure may be speedUy hoped for if the eruption is not of long standing.
(86)
X
o
LICHEN RUBER.
Tlie best local treatment wliicli I have used is tlie application of carbolic acid in full
strengtli to the patches and to the scattered lesions. This lessens the hypersemia and promi-
nence of the papules, and soon converts them into dull, red upots, which slowly disappear.
LICHEN RUBER.
Lichen ruber was first recognized as a distinct affection of the skin by Hebra, who selected
the name on account of the development of papules, and the duU red hue which they present
when not whitened by a slight desquamation of the epidermis. The disease, as described by
Hebra, is one of the rarest of cutaneous affections.
A case reported by Dr. White, of Boston, a case of Dr. SherweU, of Brooklyn, illus-
trated in the first edition of this work, a case under the care of Dr. McMaster, of New York,
and the subject of the accompanying plate, are among the few cases of true lichen ruber
which have been recognized in this country. A number of cases of extensive lichen planus,
involving both trunk and extremities I have seen, but these seein to me to differ in their na-
ture from the lichen ruber of the Germans ; and from my clinical study of cases at home and
abroad, I am disposed to differ with the majority of dermatologists who associate lichen
planus described first by Wilson, and later by other English dermatologists, with the lichen
ruber of Hebra and other German writers.
Piffard is inclined to believe that the affections are distinct, and writes as foUows : " This
view, that L. planus and ruher are identical, supported by such eminent authority, is very
plausible, and might be accepted as definite, were it not for certain prominent facts which its
advocates fail to satisfactorily explain. In the first place, Wilson observed fifty cases of L.
planus characterized by umbilicated papules and pigment stains, most of which pursued a be-
nign course. Hebra observed fourteen cases without umbilicated papules or stains, most of
which terminated fatally. It is hardly supposable that a careful observer like Hebra would have
overlooked the umbUications, if present, or that Wilson should have met with mild cases
only, and Hebra with severe ones. Now, subsequent to Wilson's publication, Hebra and
Kaposi have observed a number of examples of a benign, umbilicated, papular eruption,
which they have included under their old name of '■ruber.'' It does not follow, however,
that because they have done this, that the two are the same disease. Neumann, in 1868,
described the microscopical appearance of the original L. ruber ^ and Biesiadecki, in 1872,
those of the umbilicated eruption. As will be seen later, these differ widely. Lastly, no
one, so far as I am aware, has seen the transition of a typical L. planus into L. ruber. ^' The
latest microscopical investigations into the natiu'e of the affections by A. R. Robinson tend
to show this non-identity. After a careful comparison of the symptoms, histology, prognosis
and treatment of the two forms of eruption, this writer concludes that lichen ruber and
lichen planus are two entirely distinct diseases of the skin, and that the grounds for regard-
ing them as but two forms of the same disease are altogether untenable.
In many respects lichen ruber resembles lichen planus, and it is only necessary to refer
(87)
DISEASES OF THE SKIN— INFLAMMATORY.
briefly to certain points of difference, without discussing the question as to whether the two
are distinct affections or forms of the same disease. The papules at the outset are of a
brighter red color, conical in shape, and surmounted by a thin, adherent scale. ^Vhen aggre-
gated, as is usually the case, the same roughened surface is produced as in lichen planus.
The eruption affects no particular locality, but tends to become general. The naUs suffer
In a characteristic manner, becoming thickened, with an uneven surface and a broken ex-
tremity. This condition, together with the infiltration of the skin, interferes considerably
with the free use of the hands and feet. When the disease has existed for some time, the
patient tends to become emaciated, and in time the strength fails, and death ensues. The differ-
ent prognosis given by different writers results evidently from the fact that some confound
the general eruption of lichen planus Avith the true lichen ruber. Whereas, a cure may
confidently be expected in the one case, it can only be hoped for in tLe other.
As to the pathological nature of lichen ruber, Auspitz denies that it is an inflammatory
affection, and claims that the lesions result from a hypertrophic gro^^'th of the corneous
layer. In this view he is supported by Eobinson, who states that the primary and principal
changes in lichen ruber occur in the corneous layer and are never the result of an inflamma-
tion. He says: "From a clinical study of the papule there is also nothing in its mode of
origin or appearance which makes it probable that the disease is an inflammatory one. The
redness present is principally a hypersemic redness, as shown by the absence of an inflamma-
tory areola, there is no pus-formation, no abscess, no vesicles, no erosion, no exudation upon
the free surface, no inflammatory infiltration into the cutis, no pain ; no increase of temjpera-
ture, judging by the feel — in other words, the essential clinical characters of an inflamma-
tion are absent."
Treatment. In lichen ruber, a long continued course of arsenic is advised by Hebra,
whUe the effect of the linseed oil treatment of Dr. SherweU, in the case illustrated in the first
edition of this work, would suggest its trial in other cases. Locally, baths and other sooth-
ing measures are called for when the amount of congestion is extreme.
LICHEN SCROFULOSUS-
This is an affection which is rarely met with in this country. The eruption is a chronic
one, and is characterized by groups of smaU, pale red and scaly papules, which usually are
located upon the trunk and are not itchy. The affection is most frequently observed in boys,
and as the name implies, is commonly associated with marked evidences of a scrofulous dia-
thesis. Hebra, who first described the disease, treated all of the cases successfully by cod
liver oU, internally and externally.
PRURIGO.
This is another affection which is rare in this country, though comparatively common in
certain parts of Europe. The name Prurigo is often applied to certain itchy affections which
(88)
HERPES FAC
PRTJRIOO.
were classed under tMs head by Willan and later Englisli dermatologists, but it should be
restricted to a peculiar and extremely chronic eruption which affects chiefly the extensor
surfaces of the extremities, and is accompanied by the most intense pruritus.
The affection is never hereditary nor contagious. It is most likely to affect weakly or
poorly nourished children, and especially those whose parents have sho\vn evidences of
tuberculosis. It is rare to find more than one child in a family suffering from this disease.
Diagnosis. Prurigo is so rare in this country that only a few undoubted cases have
been reported. In my own experience I have never met with a typical case, such as may be
seen daUy in the Vienna clinics, but have treated several which were of a mild type of the
affection. Many experienced dermatologists in this country are disposed to dispute the cor-
rectness of the diagnosis of prurigo, if the well-marked symptoms of the disease, as they
have studied it abroad, are not present. But it must be borne in mind that only the most strik-
ing cases of prui'igo agria are exhibited in the Vienna clinics, and that the mild form of the
disease does not present the well-marked thickening and pigmentation of skin, with the ac-
companying buboes, which are characteristic of the severer form of the disease. It appears
to me quite probable, therefore, that many mild cases of prurigo are overlooked in this
country, cases which could pass readily as prurigo mitis in Germany. In its incipient stage
the affection might easily be mistaken for an urticaria of the extremities, as wheals and
excoriations are the only lesions. But the persistence of the disease for months and years
in spite of ordinary treatment and their characteristic localization, ought in time to reveal
the true nature of the disease. The artificial eczema, so commonly jDresent in severe prurigo,
tends usually to obscure the diagnosis, but here again the seat and persistence of the erup-
tion is a guide. While eczema is especially apt to occur upon the flexor aspect of the joints,
where the skin is thin and delicate, prurigo, of however intense a grade, invariably leaves
these parts unaffected. The eruption of scabies often bears a strong resemblance to mild
prurigo upon the extremities ; but whUe the former affection is most noticeable as a rule upon
the hands and certain portions of the trunk, the latter affection is most marked upon the
extremities.
Treatment. There are few affections of the skin and none of the inflammatory group
which are more intractable than prurigo. Taken at the outset, a favorable progress may be
made, but when the disease has existed for a long time its cure is by no means an easy mat-
ter, and under the most favorable circumstances the treatment must be continued for a year
or more. In some cases relapses are inevitable after an apparent cure, while in others the
most that can be hoped for is an alleviation of the patient's misery. Often the disease per-
sists throughout the patient's life, which is very apt to be shortened by the suffering which
it entails.
The first aim in treatment will usually be the cure of the artificial eczema which is so
often present, and to effect this the applications already recommended in connection with
eczema may be employed. The next aim mil be to lessen the infiltration of the skin, and
thereby relieve the pruritus which is so harassing to the patient. The use of tar is advisable
DISEASES OF TEE SKIN— INFLAMMATORY.
to effect this end, or if the eczema has been completely subdued, Vleminckx solution, as
recommended by Hebra, may be rubbed over the thickened skin and the patient placed for
an hour in a warm bath. This may be repeated daily for several weeks, and then continued
at intervals. After the bath the body should be anointed with lard or petroleum to coun-
teract the caustic effect of the lime in the solution mentioned, which is prepared according to
the following formula.
9 Quicklime, 10 parts.
Sublimed sulphur, - - - - 20 "
Water to 200 "
Boil to 100 iiarts and filter.
M.
The general health of the patient must be improved in every possible way.
HERPES.
Herpes, a term old enough to have been used by Hippocrates, has been applied, by wri-
ters in times past, to numerous and varied affections. Even at the present time there are
some who apply it, with varying adjectives, to both vesicular and bullous, as weU as to para-
sitic, affections. The tendency of modern dermatology has been toward a limited applica-
tion of the term to acute affections, characterized by the development of vesicles in groups.
From a clinical point of view, I deem it advisable to regard zoster and erythema buUosum
(hydroa), two vesicular or vesiculo-bullous affections, as distinct from the ordinary herpes,
60 frequently met with upon the lips and prepuce.
Herpes may be defined as an acute inllamatory affection, consisting of one or more groups
of vesicles, occurring on the face or external genitals, and in the foi-mer location accom-
panied frequently by fever. This definition limits the application of the term to two com-
paratively insignificant forms of vesicular eruption, called in accordance with the regions
affected, H. facialis and H. progenitalis.
Herpes /aciaZi^, in its most frequent form, is met with upon the margin of the lips, consti-
tuting what is commonly termed a cold sore (H. Idbialis). The vesicles, in such a case, are not
usually distinct, and the person affected may note but one or more slight swellings of the
lip, attended by an unpleasant burning sensation, and the rapid development of a thin crust
or scab. The affection may result from no apparent cause, but the patient is frequently con-
scious of having " caught a cold." The eruption often extends from the vermilion border of
the lip upon the cutaneous surface, and groups of vesicles are seen upon the side of the nose and
cheeks. When developed to this extent, the eruption, particularly in children, is apt to be
associated \vith more or less fever. In rare instances, the forehead, eyelids, ears, as well as the
mucous surface of the tongue and buccal cavity become the seat of the eruption. However nu-
merous may be the group of vesicles, they are usually developed simultaneously, the affection
differing in this respect from zoster and hydroa. The vesicles develop upon an erythematous
(90)
HERPES.
base, are rouuded and tense, and though larger than the vesicles of eczema, are not equal in size
to those seen in cases of erythema buUosum. An uncomfortable, burning sensation accom-
panies their outbreak, but subsides as soon as the eruption has attained its maximum devel-
opment. There is never any of the neuralgic pain which is so common a feature of zoster.
The vesicles rarely rupture when protected from external irritation, but dry speedily, in the
coui'se of a week, to thin, dark crusts, which fall and leave a slightly reddened surface. In
certain patients, there is a marked tendency of the eruption to recur at intervals.
The etiology of facial herpes is not thoroughly understood. That it is frequently
due to reflex nervous irritation is quite apparent from the fact of its common occurrence in
the early stage of pneumonia, and in the urethral fever following internal urethrotomy.
The old idea that its occurrence is a favorable prognostic sign, appears to have no scientific
basis.
Herpes progenitalis consists in the eruption of one or two smaU groups of vesicles on an
erythematous base, and is unaccompanied by fever. In the male the sheath of the penis
the prepuce or the glans may be its seat, while in the female it may be found u^dou the labia
and pubes. When upon a cutaneous surface, it is usually recognized without difficulty, but
upon the mucous sui'face of the genitalia the vesicles become quickly macerated, and a mere
erosion results. Herpes of the internal surface of the prepuce is a quite common affection,
and one which is frequently regarded by both patient and physician as being of venereal
origin. This may be the case, as the irritation of the sexual act may evoke the eruption,
especially in one predisposed to herpes of this part. Moreover, it may be the result of direct
contagion, since the serum contained in the vesicles has been successfully inoculated. But
usually herpes of the prepuce is an innocent affair. The affection frequently occurs in those
who have never had any venereal disease, nor indulged in impure intercourse. The vesicles
are usually accompanied by slight soreness, and in some cases by a decided pruritus. If the
part is in a cleanly condition, the eruption runs a rapid course, and disappears in four or five
days. A tendency to recur is noted in certain patients, as was seen in the case of herpes of
the face. Those who have suffered from venereal disease are especially liable to recurrent
attacks, some patients suffering in this way for years. Shortly after the healing of a chan-
croid, herpes is prone to occur, in which case it is very apt to be erroneously regarded as a
relapse, or a fresh infection.
In private practice progenital herpes is usually observed in the male, but the affection
is by no means confined to either sex, and among prostitutes official examinations have de-
monstrated its frequent occurrence.
Treatment. The treatment of facial herpes is mainly expectant. A dusting powder
is the best external application when the eruption is extensive. Spirit of camphor, or some
similar stimulating liquid may be applied frequently to an incipient " cold sore " in the hope
of checking its development. If it fails, as it generally does, cold cream may be applied with
good effect, for the purpose of softening the crust which forms.
The treatment of progenital herpes is simple. Keep the part clean and dry.
(91)
DISEASES OF THE SKIN— INFLAMMATORY.
ZOSTER.
Synonyms — Herpes Zoster — Shingles.
The name Herpes lias been used by dermatological writers as a generic term to include
all eruptions in wMcli groups of vesicles are present. This use of the term associates Zoster
■with Herpes of the lips and prepuce, and with other rarer affections, which differ widely in
their clinical features. It is advisable, therefore, to class Zoster as an affection sui generis.
The characteristics which serve to distinguish Zoster from Herpes may be concisely stated as
follows. Zoster is almost invariably unilateral, and rarely occurs more than once in a life-
time. It presents large isolated patches of tense vesicles, seated on a highly congested base,
and usually following the course of a cutaneous nerve for a considerable distance. It is asso-
ciated with a neuralgic pain and a lancinating sensation in the affected skin. It usually runs
a regular course of from two to four weeks and occasionally leaves cicatrices. Herpes is
usually bilateral if at all extensive, and may be tolerably symmetrical. It occurs many times
in the same patient. There is no tendency to distribution along the course of a single nerve
for any distance. The pain is not of a neuralgic character. There is a great variation in the
severity and course of the affection, and no scars are left.
Zoster may be defined, therefore, as a vesicular eruption, remarkable for its unilatei-al
occurrence and its limitation to the cutaneous distribution of one or more nerves. Though
not a very common affection it is one easily recognized, and is generally kno^vn among the
laity by the name of ''shingles." The eruption usually occurs upon one side of the chest
or waist, forming a portion of a gii'dle, from which circumstance is derived the name. It
may also occur upon the head or limbs, following in every instance the course of a nerve. It
is only in extremely rare cases that the eruption is bilateral. The sexes are about equally
liable to attacks and the eruption occurs at almost any age. In children it is annoying while
it lasts, but no neuralgia is left behind, as is often the case in the aged.
The eruption usually begins after a short febrile attack, appearing in the form of one or
more patches of intense hypersemia. A pricking or tingling sensation sometimes calls the
patient' s attention to the part before the vesicles have appeared, but usually the patch when
first seen is dotted with pearly vesicles which rapidly attain the size of hemp-seed. Fre-
quently the vesicles vary in size upon different patches in the same case, the least developed
patch bearing pin-head sized vesicles, while those upon another patch have reached the size
of small peas and are distended by a clear, yellowish serum. The vesicles usually reach their
maximum development in four days, remain tense for a day or more, and then gradually fiat-
ten. The inflammatory base changes in color from a bright scarlet to a dull crimson, and the
amber-hued contents of the vesicles become cloudy and even pustular. In the second week,
blackish crusts or scabs form, which gradually fall during the third or fourth week. The
eruption may fail to reach its full development and begin drying on thft second or third day.
There are, strictly speaking, no varieties of Zoster, the same characteristics appearing
(92)
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PEMPHIOUS.
whenever the eruption may be limited. Regional adjectives are conveniently used, such as
Z. capitis, Z. faciei, Z. nuchcR, Z. brachialis, Z. pectoralis, Z. ahdominalis, Z. lumhalis,
and Z. femoralis. The term Zoster bullosa might be applied to one of the cases Ulustrated,
in which we find an accidental elevation of the epidermis by a rapid exudation of serum and
a resulting confluence of the vesicles.
The cause of Zoster is to be found in some abnormal condition of the nervous system in
general, or in some injury or disease of the nerve supplying the aifected portion of skin.
The occurrence of the disease is usually a surprise, and no conditions exist which would lead
one to anticipate an attack.
Diagnosis. A typical Zoster occurring upon the trunk is easUy recognized, but when
the forehead, scalp or one of the extremities is the seat of the eruption, a mistake is very
apt to be made unless great care is exercised. If the case is seen when the disease is at its
height, the grouping of the vesicles and the disti'ibution of patches along the course of a
nerve serve as a guide. But frequently the case is not seen until the lesions have dried into
blackish crusts or have been disguised by some local application, and in such a case the sud-
denness of the attack, the course of the disease and the accompanying neuralgic pain are
points which must be taken as a basis of diagnosis.
Treatment. Zoster will always run its course without special treatment. It is useless
to attempt to abort the vesicles with nitrate of silver or blisters. The part should be pro-
tected against the friction of the clothing by a soft linen cloth, and starch powder may be
dusted on to absorb the fluid when the vesicles rupture. 'When severe pain is present, fifty
centigrams of sulphate of morphia may be added to fifty grams of elastic colodion (five
grains to the ounce) and painted over the patches. The application of the oil of peppermint,
as recommended by Meredith, to lessen the pain, has, in my experience, only served to aggra-
vate the suffering of the patient. Internally, the phosphide of zinc, two centigi-ams (one-
third of a grain) every three hours, has been praised. As the course of this disease is varia-
ble, it is difficult to judge of the effect of an internal remedy except from observation of
numerous cases.
PEMPHIGUS.
The term pemphigus was formerly applied to every eruption of bullae from whatever
cause, and affections of widely dififerent nature, and variable prognosis were accordingly
grouped under one head. Some of these forms of bullous eruption are now recognized as
manifestations of syphilis and leprosy. Others are manifestly the direct effect of poisoning
by certain drugs and other ephemeral causes. A peculiar class of. cases has been associated
with erythema multiforme, and these answer to the description already given of erythema
bullosum or the hydroa of some writers. Still the term pemphigus is used in a Avide sense,
and further study into the nature of bullous eruptions will be necessary before we can limi r
the application of the term to a definite disease. At present we must be content to apply it
(93)
DISEASES OF THE SKIN.— INFLAMMATORY.
to various affections which, are undoubtedly distinct in their etiology, but which are charac-
terized by the repeated outbreak of blebs of varying size and character.
The lesions of pemphigus may appear as tense hemispherical bullse from the size of a
pea to that of an egg, or as flattened and flabby blisters of cii-cular or irregular shape, often
involving considerable patches of epidermis. They sometimes rise abruptly from the normal
skin and sometimes are surrounded by a narrow red areola. The serous contents of tho
lesions are alkaline in reaction and contain albumen. They are at first clear and translucent,
but gradually become turbid or even purulent and usually dry into thin, brownish crusts.
A certain amount of fever may accompany the outbreak of the eruption, which may be
attended by more or less pruritus.
Three varieties of pemphigus are commonly described. They are acute pemphigus,
chronic pemphigus, and a peculiar form known as pemphigus foliaceus. The acute pem-
phigus, so-called, is usually the bullous form of erythema multiforme, and has little or
nothing in common %vith the chronic forms of the disease which alone I am disposed to re-
gard as true pemphigus. Bullous eruptions in new-born children which have been described
as pemphigus neonatorum, I have never had the opportunity of observing, with the exception
of those of an undoubted syphilitic character, which tertainly ought not to be called pem-
phigus. There remain then but two forms of the disease to be described, the ordinary
chronic form (pemphigus vrdgaris) and the extraordinary exfoliative form (pemphigus
foliaceus).
In pemphigus vidgaris the lesions are scattered over a limited portion or the whole extent
of the body. In some cases the repeated outbreaks are accompanied by fever, while in
others there is no perceptible rise in temperature or any notable general symptoms. The
bullse are tense at the outset, but pressure or friction soon breaks the epidermis and allows a
portion of the contained serum to escape. K the epidermis is forcibly removed a red and
moist surface is exposed which becomes quickly covered by a dry crust. This falls without
leaving any cicatrix, but pigmentation of the spot frequently remains for months, and in
some cases the whole skin becomes thickened and dark from the recurrence of the lesions.
In mild cases the skin remains for some time free from lesions, but in other cases a new crop
appears before the last one has had time to run its course, and the patient is kept in constant
misery Sometimes the bullae coalesce, and upon removal of the epidermis large excoriated
patches are left, which become coated with a diphtheritic deposit.
In pemphigus foliaceus we have generally a severe case of ordinary pemphigus in which
no tense bullse form, but in which the epidermis becomes raised in masses by a serous dis-
charge and dries in large whitish flakes, somewhat resembling mealy pie-crust. The diseasH
usually progresses from bad to worse, the desquamation increasing and painful fissures form-
ing which renders difficult all movement on the part of the bed-ridden patient. While in
young persons recovery may be hoped for with proper treatment, in adults and especially in
the aged, a fatal result is unfortunately the usual termination.
Diagnosis. The recognition of true pemphigus depends upon a consideration of the
(94)
PEMPHIGUS.
rOTTPE, E. oiEaSTAOT^
ACNE.
course of the disease rather than upon the demonstration of a few bulljc. It is highly im-
portant to distinguish the bullous variety of erythema multifoi-me from pemphigus, as the
prognosis is quite diilerent in the two affections. The distinctive features have already been
given. It is not so important to distinguish a severe case of dermatitis exfoliativa from
pemphigus foliaceus, and far more difficult a task. Indeed, there are some cases where
differential diagnosis is almost impossible, and the similarity or possible identity of the two
diseases has already been mentioned in connection with the former affection.
Treatment. Pemphigus is a disease which, resulting from an uncertain cause, is only
amenable to treatment in a slight degree. Palliative measures will do much to relieve the
suffering of the patient in aU cases, but seldom can a cure of true chronic pemphigus be con-
fidently expected. Of internal remedies arsenic has been most highly praised, and certainly
in no other affection of the skin can the curative effect of this powerful drug be more bril-
liantly displayed. Still the remedy is by no means a specific, and in some cases it fails en-
tirely to check or modify the recurring eruptions of bullse. In one case in which it appeared
to have little or no effect I found chaulmoogra oil to be a preferable remedy, and from the
undoubted value of this latter drug in leprosy and other chronic skin diseases, I should be
inclined to expect good results from its use in pemphigus.
The local treatment of a case consists in the constant application of soothing or drying
applications. From the known property of bismuth to check the discharge from a raw cuta-
neous surface, no better local I'emedy can be found. At the beginning of an attack or exa-
cerbation of the disease when the bullae are full and tense it is advisable to prick them care-
fully and to cover the collapsed epidermis with powdered bismuth and absorbent cotton.
When raw surfaces are present they should be covered with cloths spread thickly with the
following ointment.
9. Subnitrate of Bismuth, - - - 16 parts.
Oxide of Zinc, .... 15 "
Benzoated Lard, ... to 100 "
M.
In the f oliaceous form it is often necessary to keep the patient oiled from head to foot to
lessen the cracking of the inflamed skin.
ACNE.
The term Acne has been applied by some writers to nearly aU affections of the sebaceous
glands, whether inflammatory or not, and in this broad application has included comedo,
milium, seborrhcea and moUuscum. These affections depend upon pathological conditions
which are not essential elements of acne, which is a purely inflammatory affection. It is a
fact, however, that excessive secretion of the glands and accumulation of sebaceous matter
in the ducts are conditions which very frequently exist in connection with follicular inflam-
mation.
Acne, even in the restricted sense in which the term is now used, may be regarded as
(95)
DISEASES OF THE SKIN— INFLAMMATORY.
the most common of all cutaneous affections. It maybe asserted that the majoritj- of adults,
male or female, have not passed through the period of adolescence without having at least a
mUd form of acne upon either the face or upper portion of the back. These are the regions
upon which the affection is most apt to appear. In cases where the face is affected in a
marked degree, the back, shoulders and breast may be slightly affected, or remain perfectly
free • while, on the other hand, in cases where the back is covered -n-ith lesions of acne, the
face may be nearly or wholly exempt. The pustules of secondary syphilis are usually dis-
seminated over the greater portion of the body, and are sometimes erroneously termed Acne
syphilitica. These are not true acne pustules, however, and should be spoken of as the
pustular sj-philide or syphiloderm. Other eruptions of pustules occm-ring on various por-
tions of the body result from the ingestion of certain drugs, or from certain forms of external
irritation. These again are not true acne, even though produced by follicular inflammation.
They differ ia their causation, run a different course, and never demand the same treatment
as does acne. The affection which has been called Acne Rosacea is also of distinct nature
and pathology, as will be seen in the description of that disease.
The lesions of acne are either papular, pustular or tubercular in character, and often
these three varieties are present in a given case. They are scattered over certain limited
portions, and show no tendency to grouping or regularity of distribution. They vary from
a conical elevation of the size of a piu-head to a flattened tumor as large as a bean, having
the character of a superficial abscess. Their color is a bright red in patients with an active
circulation, but in lymphatic subjects with a thick, pasty skin, the follicular inflammation
is less acute in character, and the lesions present a duUer hue.
For practical purposes the only necessary division of acne is into two varieties, viz : Acne
vulgaris and Acne iridurata. The former, or common form of the affection, is so well known
as to require no detailed description. It appears in one patient upon the forehead or cheek
In the form of a few small red papules or "blotches," which may disappear in a week and re-
turn when the same dietary error, menstrual irregularity or other exciting cause is repeated. In
another patient the papules resulting from simple follicular congestion may suppurate and
form pustules. These may increase in number through new ones coming faster than the old
ones disappear. Month after month the skin becomes more and more thickened by the
products of inflammation ; soaps and ointments, lotions and balms, are used by the patient with
no perceptible effect, and finally the disease reaches the chronic and disfiguring stage which
is represented in the illustration. In time the disease disappears, even without treatment,
as it is rarely met with in middle life, but often deep pits remain on the site of former pus^
tules, and resemble the marks left by variola. In acne indurata a number of hard, subcuta-
neous nodules can be seen and more readily felt upon the face and neck. The skin over
these little tumors is sometimes unchanged in color, but as the pus forms around the deep-
seated sebaceous mass which causes the induration, the skin becomes reddened, and a small
abscess rather than a pustule is formed. This variety of acne is most common in IjTnphatio
subjects.
(96)
ACNE.
Acne is an affection which is never met with in childhood, but which usually makes i;s
first appearance at the period of puberty, and tends to disappear spontaneously before the
age of twenty-live. It is only in exceptional cases that it is met with later in life. It is
common in both sexes, and the tendency to the eruption is frequently found to be hered-
itary. ^Vhen this is not the case, it is often difficult to explain why the eruption shoiild
occur in certain young people and not in others. It cannot be whoUy attributed to indiges-
tion, sexual peculiarities or local irritation, since similar conditions frequently exist without
giving rise to acne, while on the other hand, the eruption frequently occurs in those who are
apparently enjoying the most perfect health. Although the peculiar disposition of the seba-
ceous glands of certain young people to become inflamed cannot be satisfactorily accounted
for, it is certain that there are many exciting causes of the disease, or conditions which tend
to aggravate it, and a knowledge of these is of the highest importance in the treatment of
a case.
External agencies have very little to do with the causation of ordinary acne. While it
is true that the inunction of tar often tends to plug the ducts of certain follicles and thereby
cause an inflammation, there is no reason to believe that dust and dirt allowed to collect upon
the skin has any similar effect. Indeed it is notable that many who have the least acquaint-
ance with soap and water present a smooth skin and a fair complexion which many of a
more cleanly class would give a fortune to possess. Too frequent bathing, on the other hand,
is perhaps the most frequent of the external causes of acne, and those who are unduly ad-
dicted to shower baths and coarse toweUing are most likely to keep some of their sebaceous
glands in a state of constant inflammation.
The use of face powders and cosmetics of various kinds, however useless they may be
for the purpose of beautifying the skin, have never been the cause of acne, so far as my
experience goes. Nor is a poor quality of soap liable to cause acne, or injure the skin to
the extent one might infer after reading the advertisements of various manufacturers of
this article. In short, it may be asserted that the causes of ordinary acne, as far as known,
are chiefly, if not entirely, of internal origin.
The relation of acne to the use and abuse of the sexual functions, is a subject which has
not been studied with the requisite amount of caution, and many statements have been made
by wi'iters which are not easily verified. While some claim that masturbation and venereal
excess is a prolific cause of acne, others assert that continence in young people is respon-
sible for the eruption in many cases. It is certain that both views cannot be correct, and
my own experience leads me to side with those who deny that either habit is an etiological
factor of any great importance.
The aggravation of an existing acne in the case of females during menstruation, or, as
more commonly happens, just before this period, is a fact which could hardly escape the
notice of the most careless observer. The general vascular tension which accompanies or
precedes this physiological function naturally induces an inflammation of the facial follicles
(97)
I>ISEASES OF THE SKIN.— INFLAMMATORY.
when a predisposition to acne exists, and in most young women suffering from acne, a fresh
crop of papules may be looked for at this time. But this happens in the case of those whose
menstruation is normal in every respect, and not with any special frequency among those
who are subject to dysmenorrhoea. Acne is common among women, too, who suffer from
uterine disease, and while it is quite probable that the relation of cause and effect may exist
in these cases, I must confess that it has yet to be clearly demonstrated.
In irritation of the gastro intestinal tract will be found, I think, the most common of
the exciting causes of acne. The sympathy existing between the stomach and the face is so
intimate that a hearty meal, a glass of wine, or a hot drink of any kind will immediately
cause congestion of the latter, and when the glands are obstructed or already intlamed, an
aggravation of the acne is inevitable. Acne, like urticaria, is often the direct effect of cer-
tain articles of food, e. g. buckwheat cakes, pastry or rich gravies, a fact of which the pa-
tient soon becomes conscious ; and when no article of diet appears to be responsible for the
eruption, the physician may readily discover that gastric catarrh, hepatic torpor and consti-
pation are important etiological factors.
Diagnosis. Acne is so frequently associated with comedo that some writers class them
together as varieties of the same disease. But in comedo we have simply a distension of
the sebaceous duct and gland without inflammation, which latter is the essential element of
acne. This distinction is in accordance with the classification we have adopted, but is a
matter of little importance from a practical point of view. The association of comedos with
acne lesions often aids in the diagnosis of acne from certain other affections which bear a
certain resemblance, but which do not involve especially the sebaceous glands. Hence when-
ever the diagnosis of a case is doubtful and acne is suspected, it is highly important to note
the condition of the glands in the neighborhood. For instance, a recent pustular syphilide,
with a few scattered lesions on face and shoulders, might be mistaken for pustular acne, but
if upon examination it was found that the glands of the affected skin were in a perfectly nor-
mal condition, neither inflamed nor presenting numerous black specks at the follicular open-
ings, the diagnosis of acne would necessarily be excluded. On the other hand, it would be
quite possible for the lesions of acne and syphilis to co-exist upon the face and shoulders of
a patient ; and, in such a case, the more important affection might be overlooked and left
untreated. The color of the lesions might lead to their recognition as separate affections,
but the most trustworthy diagnostic point would be found in the general distribution of
syphilitic pustules over the trunk and extremities, and the limitation of acne lesions to the
face and shoulders.
Acne and rosacea have long been classed together by ^vriters, and only recently have
they been sho^vn to be distinct affections, the one inflammatory and the other hypertrophic
in character. Nevertheless they are frequently observed to co-exist, and in certain cases it
13 almost impossible to say whether the case should be classed as acne or as rosacea, the dis-
\ inctive characteristics of each affection being present. Typical cases may be recognized by
I he following features : while acne usually occurs in youth, affects the whole of the face and
(98)
ACNE.
often the chest and back, and is generally associated with, comedos, rosacea occurs in adult
life, is limited to the middle third of the face, and contrasts strongly with the skin of the
remaining portion of the face, the follicles of which are always in a normal condition.
Teeatmext. There are certain affections of the skin in which a routine plan of treat-
ment is permissible. The remedy which cures one case will produce the same result in every
other case. But acne is not one of these affections. Indeed, we rarely meet with two suc-
cessive cases which demand the same method of treatment, and success in the management
of this common affection will usually depend upon a judicious adaptation of our therapeutic
resources to the requirements of each case. "While some patients demand nothing but local
measures, others cannot be cured without resorting to general treatment, and in a certain
proportion of cases, the sulphur and corrosive sublimate lotions upon which so many physi-
cians depend, will be found of no particular value whatever, and sometimes prove positively
harmful. My own experience in the treatment of acne has led me during the past few years
to rely more upon dietary and hygienic treatment, and less upon the application of local
stimulating applications.
From a therapeutic standpoint, cases of acne may be conveniently divided into two
classes. In one, the sebaceous element is the most prominent. In the other, the glandular
secretion is not affected to any great extent, but the vascular disturbance is the most notice-
able symptom of the case. In the former, the evacuation of pus which may have formed,
and the removal of the cheesy mass which distends the gland and its duct, is the first aim of
treatment, and its accomplishment will subdue the peri-glandular inflammation. In the latter
no local treatment is called for, unless it be a soothing and palliative application, but our
chief aim miist be to remove these varied causes which by reflex irritation tend to induce a
constant or oft repeated flushing of the face. In these cases, the affected skin is extremely
irritable, the lesions are almost urticarial in character and will not tolerate the harsh local
measures which are so valuable in a purely glandular form of the disease. A careful dis-
tinction between these two phases of acne is of the utmost importance, and 1 feel confident
that the hint which I have given as to the general plan of treatment required by each will
be worth far more to the reader than a host of formulae.
In the local treatment of acne, the curette is without doubt the best of all remedies. In
a well marked case, where numerous papules and pustules are present, a curette of large size
may be employed in the manner suggested by Behrend with a most beneficial result. The
affected skin is scraped vigorously with the instrument, and the projecting portion of the
lesions thereby cut or torn off. Pus is evacuated, the sebaceous plugs in the follicular ducts
are partially removed, and the glandular congestion is lessened by a free hemorrhage. The
procedure leaves the face excoriated and unsightly, but after a few repetitions at intervals of
three or four days, the acne lesions will have entirely disappeared, and when the redness
has gradually faded, which will usually happen after the distended glands are emptied, the
face will present a normal appearance. A bad case of acne cannot be improved so quickly
by any other mode of treatment.
DISEASES OF THE SKIN— INFLAMMATORY.
In indurated acne a lancet is required, and a mde-bladed one, with, shoulder to pre-
vent its penetrating too far, is advisable. The indurated nodules may contain pus, which
will escape after a simple puncture, but often a hard, cheesy mass is seated deep in the skin,
and becomes a constant source of inflammation. A puncture which only allows a few drops
of blood, or even a little pus, to escape, is hardly of sufficient benefit to warrant the pain
which it causes. The deep-seated mass of hai-dened sebum must be removed, and to effect
this, it is necessary sometimes to make a tolerably free and deep incision. A convenient
instrument which I would be loath to dispense with in the treatment of acne consists of a
tubular handle \vith a small curette screwed upon one end and an acne lancet upon the other.
When not in use the curette and lance are inside the handle, so that the instrument can be
carried in the vest pocket. In evacuating the inspissated contents of the glands, when they
axe not inflamed, but project as little white granular tumors (acne albida), the epidermis may
be lightly pricked with the lancet, and the cheesy mass extruded by pressure of the point of
the curette as explained in speaking of the removal of comedos. (Page 14.)
Soap frictions are of value in those cases of acne where the lesions are small and numer-
ous. When they are few and far between, it is unnecessary to inflame the whole skin of the
part treated, but preferable to use the curette. The officinal green soap, or ordinary soft
soap, or the Tinctura saponis viridis may be used in the following manner : Before going to
bed, a piece of flannel or lint is first dipped in hot water, and then upon this the soap is
applied to the face. The skin should be scrubbed vigorously for five or ten minutes, and
the face then bathed in hot water, and nothing of a fatty nature applied. In a few days the
skin usually becomes red and painful, and the patient often objects to the treatment, as it
does not improve the appearance of the face. It is important, however, to continue the
frictions until a considerable degree of artificial inflammation is excited, as will be seen by
a tendency of the epidermis to peel, and in some cases it will be necessary to have the pa-
tient leave the soap upon the sldn all night. When the skin is sufficiently inflamed, the
soap frictions should be discontinued, and a soothing ointment applied to the face. In
a few days the acute inflammation will have subsided, and the skin will appear much
smoother and softer than before the treatment began. In obstinate cases, it is often neces-
sary to return to the use of the soap several times before the skin will present a natural ap-
pearance, each series of frictions removing many of the comedos and acne lesions. Even
when the skin has become quite smooth and free from acne, a certain amount of redness will
often remain, which can be treated by one of the numerous sulphur ointments or lotions of
which the f ollo^ving are samples.
M.
Washed Sulphur,
10 parts
9
Precipitated Sulphur,
- 15 parts.
Carbonate of Potassium,
- 5 "
Tannic Acid,
2 "
Ether, . . . .
16 "
Glycerine,
- 3 "
Glycerine, ...
5 "
Cologne Water,
30 "
Alcohol, to . . .
100 "
M
(100)
Mucilage of Starch, to -
100 "
>
z
<
ACNE.
9 Washed Sulphur, - - 10 parts. '^ Precipitated Sulphur, - 5 puixs.
Tincture of Benzoin, - 10 " Tannic Acid, - - - 6 "
Mucilage of Starch, to - 100 " Petrolatum, to - - - 100 "
M. M.
The local use of sulphur is often beneficial in acne, as it serves to stimulate the circula-
tion, lessen the passive hypersemia and thus to bleach the complexion, but the remedy \vill
not reach the cause of the congestion nor have any effect in emptying the contents of the
torpid glands, and hence the common practice of depending wholly upon some sulphur ap-
plication for the cure of acne is manifestly absurd and is usually the secret of the frequent
failure in treatment. In mild cases of acne among young women the precipitated sulphur
may be used as a face powder, but the benefit derived from its use in this manner is slight in
comparison with what has been claimed for it. In chronic cases with much inflammatory
thickening of the skin and little or no tendency to suppuration the iodide of sulphur oint-
ment of varying strength will be found serviceable. In prescribing sulphur as an applica-
tion to the face in any form the physician must always bear in mind that its chemical com-
bination with lead or mercuiy in the follicles of the skin wiU produce a multitude of black
specks which often look worse than the red blotches of acne. The patient should be
questioned as to whether any lead or mercurial applications have been recently made to the
face, and if so, the skin must be scrubbed thoroughly mth soap and hot water before it wiU
be safe to prescribe the use of sulphur. Mercurial applications are of comparatively little
benefit in most cases of acne, although corrosive sublimate is an ingredient of many of the
cosmetic lotions intended to beautify the skin and which are often recommended in the
treatment of acne. When it is necessary to give some pleasant local application to satisfy
the patient while the indigestion or other cause of the acne is being gradually removed, one
of the following may be ordered.
9 Corrosive Sublimate, - - 1 part.
Chloride of Ammonium, - 2 parta^
Cologne Water to - - 200 "
M.
9 Corrosive Sublimate, - - 1 part.
Subnitrate of Bismuth, - 15 parts.
Mixture of Bitter Almonds to 600 " Camphor Water to - 600 "
M. M.
While local treatment is of great value in many cases of acne there are some in which
it is capable of producing very little benefit, and in a great majority of cases general treat-
ment is of the utmost importance. In that large class of cases of irritable acne occurring in
women where the vascular disturbance is a more prominent feature of the affection than any
anomaly of the sebaceous secretion, my experience has led me to discard local treatment and
to depend almost entirely upon dieting and hygienic regimen.
(101)
^
Corrosive Sublimate,
1 part.
Thymol,
4 parts.
Alcohol to - - -
- 100 "
M.
V^
Corrosive Sublimate,
- 1 part.
Dilute Hydrocyanic Acid,
- 10 parts.
DISEASES OF THE SKIN.— INFLAMMATORY.
The effect of a modified or restricted diet is usually more marked in acne than in almost
any other affection of the skin. There is usually some form of iadigestion at the root of the
trouble; and although many confirmed dyspeptics have a fair complexion, and many acne
patients scorn the imputation that there is anything the matter with their digestion, I must
say that I constantly find that a change in the quantity and quality of their food Avill pro-
duce an immediate amelioration of the eruption and notably improve the general health.
Tea and coffee, as well as wine and beer, must be forbidden. The diet must be of the plainest
and most nutritious kind, and not only should highly-seasoned food, rich gravies, pastry,
cake and candy be excluded from the dietary list, but every article of food, the propriety of
eating which is open to suspicion, should be resolutely put aside. The meals should be taken
regularly and deliberately. Little if any water should be drurk at meal time, but a large
amount can be taken with benefit about two hours after each meal, when the digestive pro-
cess is nearly completed. This will often relieve the habitual constipation and frequent
headaches from which acne patients are disposed to suffer. In many cases the stomach
needs a rest, and it is sometimes advisable to allow but one full meal daUy, the breakfast and
lunch (or supper) consisting of merely a slice of brown bread, with a little fruit or glass or
two of milk, if this is found to agree with the patient. An increased amount of exercise
should be prescribed with the restricted diet. Indeed the rule to eat less and exercise more
will be found to strike at the root of acne and of- many other affections of the skin.
The Turkish bath is one of the most valuable remedies in the general treatment of acne.
An imperfect circulation, with a tendency to cold and clammy hands and feet is frequently
noted in connection with the eruption, and the bath taken twice or three times every week
will not only improve the affected skin but increase the tone of the whole system.
Of internal remedies there are two which deserve a special mention. These are calx
sulphurata and ergot. The former, by virtue of its influence upon the suppurative process
is often of great value in certain cases of pustular acne, if given in a proper dose. The
failures in the use of this drug in acne have generally resulted from its employment in too
large a dose, a grain or two daUy being frequently given. My plan is to order one-tenth of
a grain every two hours in a case of chronic, indurated acne, and to give one-twentieth, one-
fifteenth or even less at a dose in the more acute and irritable cases.
Ergot may be given, as recommended by Denslow, in the form of a fluid extract, a half
drachm three times daUy, or three grain pills of ergotine may be employed. Any digestive
error should be corrected by suitable remedies before the ergot treatment is begun. I have
seen some brilliant results from the use of this drug, and have seen it productive of no
beneficial result whatever in other cases. It appears to act best in the case of lymphatic
subjects, with a thick, pasty skin and sluggish circulation, which fact woiild seem to corrobo
rate Denslow' s view that the ergot cures the acne by virtue of its action in contracting the
arrectores pilorum or little muscles which run beneath the sebaceous glands, and /.ot aa
(jthers have supposed, through its action upon the capillary vessels.
(102)
SYCOSIS.
SYCOSIS.
Synonym — Barber's Itch.
Sycosis is an inflammatory disease of the hair follicles, usually affecting the bearded
portion of the face. It is characterized by tenderness and swelling of the skin and the
development of deep-seated nodules and superficial pustules, each one of which is usually
perforated by a hair. The affection is allied to acne and differs from it in its anatomical
seat, the inflammatory process taking place in and around the hair follicles instead of the
sebaceous glands.
The affection often begins suddenly Avith a heat and tension in the part, and the primary
starting point of the inflammation, according to Robinson, is in the connective tissue around
the hair sac, thus constituting a perifolliculitis. The follicle becomes quickly involved
and the pus reaches the surface of the skin between the hair and the follicular wall. The
lesions may be scattered over the cheek or chin, but since inflammation of one follicle is very
apt to extend to those in the vicinity, the eruption is usually found in ill-defined patches
where the lesions are crowded. It is rare for the whole bearded portion of the face to be
involved, and this never occui's except in extremely chronic cases. Occasionally the eye-
brows and eye-lashes, the scalp, neck and pubic region are affected.
The course of sycosis is variable. In some mild cases it may tend to a spontaneous cure,
but generally it becomes a chronic and most annoying affection. When the follicular suppu-
ration has been profuse the matrix of the hair is often destroyed and permanent baldness of
the affected part is the result.
Sycosis is a disease of adult males. It often attacks the robust, although its worst phases
are generally observed among those who are weak or in poor condition. It is seldom met
with upon the face of those who are addicted to the daUy use of a razor. The proximate
cause has been supposed to be the premature gro^vth of new hairs in the follicles, the small-
ness of the f oUicle in proportion to the size of the hair, the irritation resulting from the use
of a dull razor, etc., etc. The etiology is generally obscure and does not throw much light
upon the treatment of cases.
Diagnosis. It is sometimes difficult to distinguish sycosis from trichophytosis barbae,
which, in some instances, assumes a nodose foi-m and presents a true folliculitis. This is de-
scribed by some writers as a distinct affection from ordinary ringworm, and is called sycosis
parisitaria. In this affection there is usually a considerable amount of subcutaneous inflam-
mation, and the affected skin often swells up into a fig-like tumor, which, subjected to pres-
sure, oozes pus at every follicular opening. In the vicinity and upon other portions of the
body the typical scaly patches of ordinary ringwonn are often present and thereby reveal
the parasitic natui-e of the affection. The history of contagion and the friability of the hair
will sometimes lead to a correct diagnosis of the cause of the folliculitis, but in aU cases of a
doubtful character the microscope must be relied upon to determine the presence or absence
of the trichophytic spores.
(103)
DISEASES OF THE SKIN— INFLAMMATORY.
Sycosis bears a strong resemblance to a pustular eczema, and Pifiard and some otlier
excellent dermatologists deny that the affection is distinct in its nature. While it is true
that eczema often attacks the bearded portion of the face and in some instances does not
confine itself to its favorite anatomical seat in the mucous layer of the epidermis, but also
involves the follicles, and thus induces a folliculitis or secondary sycosis, there yet remain
many cases in which there is simply a follicular inflammation Avithout any tendency whatever
to that catarrhal inflammation of the skin, which is the essential element of eczema.
In eczema of the beard the eruption is apt to extend upon the hairless parts, and especi-
ally to appear about the ears. The hairs are never loosened however intense the cutaneous
inflammation may be, and there is frequently a weeping surface. In sycosis the eruption is
invariably restricted to the haiiy parts. The suppuration \vithin the foUicles produce a loos-
ening of the hair and often a spontaneous depilation, and however thick the pustules and
crusts may appear upon the surface of the skin, there is never any superficial serous exuda-
tion such as is observed in eczema.
A tubercular syphUide of the bearded portion of the face might be mistaken for sycosis
on account of the presence of nodules and crusts, but the grouped and circular character of
the tubercles, and the complete absence of pain or a burning sensation would point to syphilis
rather than to sycosis.
Treatment. Although sycosis often proves to be a chronic and rebellious affection
there are few if any cases in which a judicious plan of treatment ^viU not effect a cure in a
reasonably short time. Local measures are of chief value, although in every case sucli gen-
eral treatment as will conduce to an antiphlogistic effect upon the skin ought not to be neg-
lected. Restricted diet and mineral waters will usually do much to relieve the congestion of
the skin and thereby lessen the pain which in some cases is a prominent feature of the
disease.
At the beginning of our treatment it is always advisable to have the face closely shaven
if the patient Avill submit to this procedure. If the skin is too tender to allow the use of a
sharp razor, the hairs may be clipped as short as possible and a hot poultice applied. The
next step is to remove by means of the epilating forceps all hairs which are loosened by the
follicular suppuration and as many more as will yield to the slightest traction. In some cases
this is an extremely painful operation, and I have known strong men to wince and shrink at
every approach of the forceps to the face, and after the removal of a few hairs declare that
they could not possibly bear to have more removed that day. The effect of the removal of a
few hairs which act like thorns in the inflamed flesh, is always notably beneficial, and by per-
sistence in this method of treatment a relief of the pain and swelling is obtained which no
soothing ointment or lotion could possibly produce. When all the loose hairs are removed
the oxide of zinc ointment or the following may be applied in place of the poultice.
9- Lead plaster, 20 parts.
Carbolic Acid, 6 "
Petrolatum, to . . . . lOO "
M.
(104)
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O
O
<
o
u
O
o
W
(X
o
o
s
o
a,
PORRIOO.
Frora week to week such hairs may now be epilated as appear surrounded by a papule,
and soon the tendency to pustulation will be found to have ceased entirely. The skin often
remains somewhat thickened and red for a month or two, and when the epilation is no longer
deemed necessary the affected hairs may be rubbed nightly with a five per cent, oleate of
mercury or the white precipitate ointment.
The progress of a disease towards a cure is not always uniform, and frequently a relapse
occurs -with a sudden increase of pain and swelling in the affected skin. In such a case it is
necessary to suspend any stimulating plan of treatment for a few days, and often advisable
to prescribe pugation and poulticing until the acute inflammation has subsided.
PORRIGO.
Synonym — Impetigo contagiosa.
The name Porrigo has been applied by the older writers on skin diseases to so many pus-
tular, as well as non-pustular affections of widely different nature, that, at the present day
it is scarcely able to retain a position in dermatological nomenclature. As there exists, how-
ever, a contagious pustular affection of the skin, which is neither eczematous nor unmistaka-
bly parasitic, and to which no settled name is attached, I am disposed to follow the example
of Startin, Nayler, and Hutchinson, and to apply to it the old and misused term, Porrigo.
The affection is an acute one, and is characterized by a rapid development of one or
many flat, vesico-pustules, which spring from an apparently normal skin. These are quite
superficial, tend to enlarge peripherally though remaining flattened, and usually attain the
size of a ten-cent piece. The crusts which form are thick, friable, varying from a straw color
to a greenish-yellow, or brownish hue, and often presenting a central depression, like a vaccine
crust. They are lightly adherent, and when forcibly removed, expose a raw, purulent sur-
face, but no deep ulcer. When allowed to dry and fall, a thin, reddened epidermis remains
for a short time, and disappears vrithout leaving a scar. The chief peculiarity of the pus-
tules is their contagious character. When occurring, as they frequently do in connection
with phtheiriasis, it is quite apparent that they tend to develop whenever the skin is exco-
riated, and it appears quite probable that the pus partakes of an infectious nature, and is
carried from one point to another by the finger-nails. New pustules may be readily pro •
duced by intentional auto-inoculation. The affection is quite common among children, but
it also attacks adults. Frequently several members of a household are successively affected,
and epidemics have been reported to occur. The pustules are most frequently met with upon
the scalp and face. The trunk and extremities, and particularly the fingers, may also be its
seat. It occasionally develops when no apparent cause exists. Local irritation of some
sort, however, can generally be detected, and to the irritating preseiice of pediculi the affec-
tion is frequently attributable. A fungus has been described as existing in the crusts, but it
has not been proven to be the essential cause of the affection.
A bullous form of the disease I have recently had the opportunity of observing at the
(105)
DIS£A SiiS OF TEE SKIN—INFLAMMA TOR Y.
I^urseiy and CMld's Hospital, tlirongli the kindness of Dr. E. L. Partridge. The eruption
might have passed for an acute pemphigus, but the typical character of the lesions in one
case and the strong probability of it having affected three other children through contagion,
appeared to me sufficient to establish the diagnosis. These latter children were thin and
weakly and the eruption was mostly confined to the neck and breast. Bullae as large as a
walnut, though not tense, formed in numbers. The whole neck became almost denuded of
epidermis, leaving a dry reddened patch of skin with a peeling border. In only one of these
cases was the eruption accompanied with fever.
Diagnosis. The diagnosis is easy, although some confusion aiises from the varying
descriptions of Impetigo and Eczema impetiginosum which are found in the text books.
The term Impetigo is regarded by most recent \vriters as a synonym of pustular eczema, "an
eczema," according to Tilbury Fox, " occurring in a pyogenic habit of body." The Impetigo
contagiosa, described by this late writer, appears to me to be simply a form of Porrigo which
occurs largely among children, and is usually accompanied at the outset by slight febrile
symptoms. Such cases I have had repeated opportunities of studying, and have verified the
admirable description of the eminent English author. I see no reason, however, why the
name which is applied to these cases (be it Porrigo or Impetigo contagiosa), should not also
be applied to an eruption of isolated, contagious, vesico-pustules in adults, although unac
companied by febrile symptoms, and occurring as a complication of phtheiriasis.
Treatment. To cure the affection it is first nesessary to remove the crusts, which can
be done without violence after the application of a poultice or folded cloth Avrung out of
hot water. A five per cent, ointment of carbolic acid may then be applied to the affected
skin for a few days. In many cases the lesions tend to run a definite course of from one to
three weeks, and sometimes they do not yield to treatment as readily as their superficial
character would lead one to expect.
ERYSIPELAS.
Erysipelas is an infectious disease characterized by an eruption which, starting at a
given point, gradually involves succeeding portions of skin. This is always accompanied by
fever, and usually a chill, or succession of chills, \vith general lassitude for several days, pre-
cedes the eruption. When erysipelas occurs spontaneously, some portion of the face, and
usually the bridge of the nose is the starting point. The eruption begins as a red and tender
lump, upon which pressure of the finger leaves a temporary yellowish pit. It spreads grad
uaUy, becoming deeper in hue, and the advancing border of the patch is always abruptly
raised, like a wall, above the healthy skin.
In connection with the fever and cutaneous inflammation, some of the internal serous
membranes may be inflamed. In every severe case of erysipelas of the face and scalp there
is usually more or less swelling of the throat, and a fatal result is not unfrequently the result
of ODdema of the glottis, or cerebral congestion. On the other hand, the disease sometimes
produces an unexpectedly favorable result, and patches of erythematous lupus and chronic
(106)
EBTSIPELAS.
eczema, or leg ulcers, may disappear entirely or be greatly benefited in consequence of an
attack of erysipelas. When tlie affection recurs frequently in the same locality, as it some-
times shows a disposition to do, a chronic csdema ensues, which in time leads to a marked
thickening and induration of the skin as in elephantiasis.
The cause of erysipelas is, without doubt, an infectious germ which usually finds an en-
trance into the system through some abraded or raw surface, such as an idcer or fresh wound.
Even when it commences upon the unbroken skin of the face, without any known exposure
to contagion, it is quite possible that some stray germ of the disease has been absorbed
through some trifling lesion of the nasal mucous membrane.
Erysipelas may begin within the nose or upon the mucous membrane of the pharynx
and by extension through the nasal passages reach the skin. It frequently has its starting
point at the umbilicus of the new bom child, and in such a case it sometimes extends over
the whole body and terminates fatally. Its occurrence after vaccination is not uncommon,
and the tendency which it frequently manifests in hospitals to occur in epidemic foi-m and to
attack every raw surface naturally renders it the dreaded foe of surgeons.
The lids of one or both eyes usually become (Edematous and tightly closed. The mouth
can scarcely be opened when the lips are involved, and in some cases the features become so
changed in appearance that the patient would scarcely be recognized. The swelling of the
ear usually prevents the sufferer from lying upon that side, and when the patch has ex.
tended over the scalp, the pain from pressure of the pillow is apt to be severe and annoying.
Occasionally the eruption extends down upon the back.
In most cases, the swelling of the skin and the accompanying pain lessen in a few days^
60 that the parts first attacked become smooth, or merely covered with a desquamating epi-
dermis, while the active inflammatory pi-ocess is invading new territory. The surface of the
swollen skin is frequently the seat of vesicles, or bullse, which dry and form crusts as the
Bwelling subsides. Sometimes, in old persons, gangrene of the skin occui's.
Diagnosis. Erysipelas may be readily distinguished from erythema, eczema and other
inflammatory skin affections by the general febrile symptoms which accompany the eruption,
the pain and swelling of the affected part and the abrupt margin of the advancing patch.
There is a cellulitis, however, which is erysipelatoid in character and which is often difficult
to distinguish from the true disease.
Treatment. An appreciation of the infectious nature of erysipelas ought to be of great
service in its prophylaxis. Although many cases appear to be spontaneous, and cannot
possibly be avoided, there are some which are the direct result of carelessness, and for which
the physician or surgeon should be held responsible. Surgical instruments, and especially
the vaccine lancet, should be thoroughly cleaned by some disinfectant fluid after every ope-
ration, and every case occurring in hospital ought to be isolated at the earliest possible mo-
ment. In the treatment of every case, both local and general measures are called for. Tlie
old plan of attempting to check the spread of cutaneous inflammation by painting the neigh-
(10-)
DISEASES OF THE SKIN.— INFLAMMATORY.
boring healthy skin -with iodine or nitrate of silver, is now obsolete, and our chief aim should
be to relieve the pain and swelling. This can be best effected by the application of a lead
and opium lotion or some soothing ointment. Painting the affected skin with collodion is
apt to occasion more discomfort than benefit, and is inferior to the use of compresses dipped
in hot water containing carbolic acid. ^Yhen the fever is of high grade, full doses of quinine
are indicated, and if the stomach does not tolerate the drug, it may be administered in the
form of a suppository. Iron and quinine should be given steadily until convalescence sets in.
Carbonate of ammonia every two hours has been employed successfully.
FURUNCULUS.
Synonym — Boil.
A furuncle is a localized inflammation of the skin and subcutaneous tissue, producing a
reddened, conical and painful tumor. Its essential feature is the formation of a central
Blough, in which respect it differs from simple follicular intlammation or a superficial abscess.
It begins as a small pointed papule, which in a few days has usually increased to the size of
a large pea or marble. The skin is tense and red, and at the summit of the conical tumor a
small grayish speck is apparent. This rapidly becomes pustular, and soon an opening is
seen through which the pus formed within the tumor, together with the "core" or slough-
ing tissue may be spontaneously evacuated.
BoUs are usually multiple, and develop successively, or in repeated crops. The individ-
ual tumor runs a limited course of from one to two weeks, but the tendency to the occur-
rence of others in its place often persists for several months. The neck is the favorite seat
of the lesions, but there is scarcely any portion of the body which is exempt fro?n the loca-
tion of a boU, and no spot seems to the patient so undesirable to have it as the very one upon
which it has located.
The cause of boUs is not always apparent. WhUe they are not infrequent among poorly
nourished children, and adults whose general condition is impaired by dissipation of various
sorts and by overwork, th.ey sometimes attack those who are robust and apparently in ordi-
nary health. Strangely enough, the affection is quite apt to be observed in the case of ath-
letes who are undergoing a course of training. As a direct result of diabetes, boils are fre-
quently noted, and their repeated occurrence should lead to an examination of the urine.
Diagnosis. A typical furuncle is net apt to be mistaken for any other disease of the
ekin, but the affection often runs an abortive course, and no central slough is formed. These
so-called "blind l^oils," are often met with in connection with other inflammatory eruptions,
and as described by Bronson, are a frequent accompaniment of miliaria.
Tkeatme>"t. Boils may sometimes be arrested in their incipient stage by the adminis-
tration of calx sulphurata and the other alkaline sulphides which, according to Ringer and
the experience of many others, exert a marked influence upon the suppurative process in
various affections. ^Vhen a boU is at its height, one-tenth of a grain of the drug given three
(108)
CARBUNCULUS.
or four times daily, will hasten the suppuration and natural course of the disease. Moderate
purgation for a few days with Rochelle salt or mineral water will often check the tendency
to a fresh crop of boils.
As for local treatment a poultice is of the greatest service in the incipient stage, when
pain and tension of the sldn are present. As soon as the boil "points" it should be freely
lanced, or carbolic acid introduced into the sloughing centre. The latter plan of treatment
J3 usually more agreeable to the patient. My plan has commonly been to prick the boil at
";his stage with a sharp splinter or wooden toothpick dipped in carbolic acid. As soon as
the opening is sufficiently large, a little cotton wound around the point of the toothpick and
immersed in the acid should be introduced into all parts of the furunculous cavity. This
procedure soon lessens the pain and swelling, and promotes a radical cure.
CARBUNOULUS.
Synonyms — Anthrax — Carbuncle.
A carbuncle is of the nature of the furuncle, but is distinguished from it by the greater
extent of tissxie involved, the severity of the constitutional symptoms which precede and
accompany the local inflammation, and by the gravity of its prognosis. It begins with pain
and induration of a small portion of skin, and quickly forms a flattened tumor of the size of
an egg. The skin is at first merely reddened, but gradually assumes a dull, livid hue. In a
few days a number of openings appear upon the surface, from which mingled blood and pus
can be readily pressed. A number of separate sloughs may form at these points, or the
whole tumor may become necrotic in character and form a greyish or blackish mass. This
is gradually cast off, and leaves usually a very deep ulcer, which, under favorable circum-
stances, heals slowly and produces a hard and puckered cicatrix. At the outset the pain is
excessive, and lasts until sloughing has taken place. A chill often precedes the develop-
ment of the inflammation, and a high degree of fever accompanies its progress. Inflamma-
tion of pleura or lung sometimes occurs and symptoms of pyaemia are always liable to
appear and lead to a fatal result. In many cases of carbuncle in those advanced in life,
death results from exhaustion. The seat of the affection is usually the neck or back, but it
may attack the anterior portion of the chest, or other portions of the body.
TREATMENT. The Strength of a patient attacked by carbuncle must be maintained by
beef tea and stimulants. Quinine, given in full doses, is generally of service. As in fur-
uncle, calx sulphurata will tend to check the inflammation at the beginning, and hasten the
suppuration at a later stage.-
The most approved local treatment is a deep crucial incision as soon as suppuration is
established. The pain of this operation can be lessened by previously freezing the skin with
an ether spray or an application of salt and ice. Carbolic acid may be injected subcuta-
neous] y at the very outset, and should be freely and repeatedly applied in an undiluted form
us soon as the incision has been made.
(109)
DJSEA&ES OF THE SKIN.— INFLAMMATORY.
ULCUS.
Synonym — ZTleer,
An ulcer ia a lesion of the skin or mucous membrane, characterized by loss of tissue and
slight disposition to spontaneous heaUng. In the latter respect it differs from au ordinary
wound.
Some dermatological writers do not regard an ulcer as a distinct disease of the skin, but
consider it as a mere lesion occurring in the course of various diseases. Other writers treat
of cutaneous ulcers as a distinct class of skin diseases. Certaialy the importance of these
lesions, whatever may be their cause, is an ample warrant for a separate consideration of
their peculiar features.
Ulcers in general vary greatly in size and shape, in the character of theii" surface and
border and in the condition of the surrounding skin. Small ulcers, occurring where the skin
is rather tightly drawn, are commonly circular, while larger ones may be oval, elliptical,
kidney-shaped, or irregular m outline.
The surface of an ulcer is sometimes smooth and clean, of a bright red color, and char-
acterized by the small hemispherical granulations which give promise of a speedy cicatrization.
On the other hand it may be covered with a foul secretion, which adheres to and conceals its
base, or the granulations may be of an exuberant fungous character, rising above the surface
of the skin at the margin and giving rise to the common term, "proud flesh." Frequently
these granulations are extremely painful upon the slightest pressure and bleed at the slight-
est touch. Occasionally the surface presents a diphtheritic appearance, being covered by a
yeUowish-wliite tenaceous membrane. A crust of a yellowish, greenish or blackish hue and
variable thickness often forms upon and adheres to the edges of the ulcer.
The border of an ulcer may be smooth and soft, or on the other hand elevated consider-
ably above the level of the skin and more or less indurated. The wall of this border may
slope gradually to the edge of the granulations, may be abrupt or steep, and finally the bor-
der may be undermined to a considerable extent.
Thf skin surrounding an ulcer may be in a perfectly normal condition, or considerably
inflamed and swollen. Upon the legs it is often eczematous in character and usually pig-
mented and scaly.
Ulcers occur as a result of the softening of various neoplastic growths or as the result of
an inflammatory process. In the former class we have those which are common in lupus
leprosy, cancer and the gummy deposits of syphilis. In the latter class we have both idio-
pathic ulcers and such as are caused by scurvy, scrofula and syphilis in its early stages.
Treatment. In the treatment of ulcers two main objects are to be considered, the
removal of the cause so far as this is possible, and the adoption of such measures as will tend
to convert the ulcer into a healthy granulating wound. The disease of which the ulcer is
merely an incidental feature must be treated upon principles elsewhere laid down. The
(110)
ULCUS.
intlauiiuatory condition whicli predisposes to its development must be combatted witli auii-
pMogistic measures, while the new growth, which is so often its cause, must be destroyed.
The mechanical agencies which aggravate even when they do not cause the ulcer must be
counteracted by the exercise of the utmost care and attention
Since of all ulcers, those occurring upon the leg are most common and most frequently
rebellious, the limited space at command may be best devoted to their treatment. A routine
plan will not suffice here. While one leg ulcer needs the most tender care another will only
respond to harsh methods. The first and a most important step is to decide as to the nature
or cause of the ulcer, and for practical purposes leg ulcers may be conveniently divided into
three classes, viz. : syphilitic, eczematous and simple ulcers. If the ulcer is situated upon
the upper third of the leg and not transmatic, it generally owns a syphilitic origin and de-
mands specific remedies. The same rule holds as to leg ulcers, which are kidney-shaped or
midtiple, and arranged in a semi-circle, or occurring upon a swollen ankle with deep siausea
apparently reaching to the bone. If an ulcer is surrounded by a broad zone of reddened or
pigmented skin it is usually the result of a pre-existing or present eczema. The leg is usu-
ally larger than its mate and swells considerably after the patient has walked or stood for
some time. The ulcer is apt to be painful and frequently is associated with a varicose condi-
tion of the veins. In such a case it is always advisable to put the patient to bed or to keep
the leg constantly elevated, if either course is possible. This being rarely the case in prac-
tice among the poorer classes the next best thing tp do is to bandage the leg carefully and
teach the patient to do the same every morning before getting out of bed. A light cheese-
cloth roller bandage is the best adapted to this class of cases, as a rubber bandage is liable to
cause the eczema of a congested leg to spread. If the ulcer is foul a little charcoal or iodo-
form may be applied to the surface and covered with a thick, soft muslin. If it is painful
and presents a thin ichorous discharge there is no better application than the subnitrate of
bismuth beneath the bandage. It may be advisable to apply an ointment to the eczematous
skin around the ulcer but not as a rule to the ulcer itself.
A simple ulcer, resulting originally in traumatism, may be irritable or indolent. In the
former case it needs rest and the constant application of hot fomentations. Indeed, if a patient
can be kept in bed, no matter whether an ulcer is a simple or a syphilitic one, healthy or
sloughing, there is no local treatment which, in my experience, will compare with the fre-
quent application of hot cloths. If the ulcer is indolent with a glazed surface and caUous
edges an excellent plan is to place the leg in hot water every day and puncture the iilcer and
surrounding skin with the point of a lancet until the blood flows freely from a score or more
of small incised wounds. When a large ulcer has been brought to a healthy granulating
condition the healing process can be greatly hastened by the adoption of the process known
as skin grafting.
(Ill)
DISEASES OF THE SKIN—INFLAMMATORY.
ONYCHIA.
Synonym — Paronychia.
OnycMa is a term applied to inflammation of the soft tissue beneath or around the nail.
In most cases the fold of skin rising above the lateral border of the naU is the part affected
(onychia lateralis), but sometimes the inflammation takes place at the root of the nail or in
the underlj'ing tissue.
Onychia lateralis or Paronychia most frequently affects the great toe, and constitutes a
painful and annoying affection. By the almost constant pressure of tight shoes the external
border of the nail becomes unduly curved, and the swelling of the soft parts in the immedi-
ate vicinity produce that chronic condition which is commonly known as " in-growing toe
naU." Frequently the inflamed skin at the side of the nail ulcerates, as the result of pres-
sure and fimgous granulations spring up over the surface. Paronychia of the finger nails is
usually the result of injury, and runs an acute course. Suppuration usually takes place in a
few days along the border of the nail after which the pain and swelling subsides, although
the inflammation may extend to the matrix of the nail and cause the latter to be cast off.
Inflammation of the root of the nail (onychia retrounguealis) and the underlying soft
\)ViYt (onychia subunguealis) may occur as the result of injury or in connection with syi^hilis)
variola or scrofula. This form of onychia is usually more severe and commonly results in
the loss of a portion or the whole of the nail. With the subsidence of the acute inflamma-
tion the new naU begins to form and in time rises and loosens the old one.
The diagnosis of onychia from affections of the nail substance, to be mentioned later,
depends upon the presence of inflammation.
TiiEATMENT. The Occurrence of inflammation about the nail occurring after injury may
be avoided to a certain extent by the immediate immersion of the part in hot water. When
a spontaneous paronychia is threatening, the progress of the inflammation can often be
checked by painting the reddened and slightly-swoUen skin with a ten per cent, solution of
nitrate of silver. When the inflammation is well established and especially when there is
ulceration present the best method of treatment is the constant application of the following
ointment.
^ Iodoform, 10 parts.
Balsam of Peru, 20 "
Petrolatum to .... loo "
M.
This may prove too stimulating in certain cases, and therefore be adapted only to the
healing stage of the affection, bat in many chronic and indolent cases it will produce most
beneficial results.
In all cases of onychia not of traumatic origin the possibility of its deijendence upon
f;y]ilini=! nr scrofula must be carefully considered and the appropriate general treatment
a(ln|.I.ll.
(112)
ONTCAIA.
The management of in-growing toe-nails and the frequently resulting inflammation often
requires the most careful attention and skill. The ordinary discomfort which so many expe-
rience from a slight degree of incurvation, if it be neglected, can best be relieved by paring
the comer of the naU as far back as possible after it has been thoroughly softened by a pro-
longed hot foot bath. When painful inflammation is present a broad shoe or slipper must
be worn until it subsides. When ulceration has taken place the granulating surface must be
carefully separated from the naU. This can be accomplished in the following manner : The
nail should first be scraped to render it as thin and flexible as possible. A hot foot bath will
then soften the skin and render it less painful. The edge of the nail can now be carefully
raised and a thin piece of lead or even a strip of linen pressed beneath it. Into the sulcus
beside the naU a little charpie must be pressed and the soft parts drawn away from the bor-
der of the nail as far as possible by the traction of narrow strips of adhesive plaster carried
under the toe. This plan of treatment insures speedy relief and usually effects a cure of the
trouble in the course of a month.
Avulsion of the naU or excision of the lateral portion has been highly recommended
by many surgeons, and it is claimed that the very best result can be most speedily attained
by simply cutting away the soft tissue which crowds against and over the curved edge of
the nail.
(113)
CHAPTER m.
HEMORRHAGIC AFFECTIONS.
An effasion of blood from the cutaneous capillaries may result from three causes, viz.,
external riolence, increased blood-pressure, and weakness of the vascular walls. In many
cases of cutaneous hemorrhage a rupture of the vessels takes place, but on the other hand it
is possible for the blood corpuscles to pass through the uninjured waUs of the capillaries, and
without doubt this process (diapedesis) fi-equently occurs. To all forms of cutaneous hem-
orrhage some writers have applied the term purpura, which is manifestly wrong, since it
places a flea-bite or a "black-eye" in the same category with scurvy. The term purpura
should be used in a restricted sense, and applied only to an independent disease, in which
cutaneous hemorrhages occur as a primary lesion. This excludes the hemorrhage resulting
from a blow, fall, or the bite of an insect, as also that which is due to obstruction of the
venous circulation. It excludes the hemorrhage which occurs secondarily in the course of
the exanthematous fevers (e. /7., Variola hemorrhagica), and in certain inflammatory skin
affections, such as erythema, urticaria and pemphigus. Finally, it excludes scorbutus (or
scurvy), as being an affection due to a defiaite and well-known cause.
Cutaneous hemorrhage may occur in the form of numerous punctate spots I'esembliiig
Tleabites (petechise), as fine lines or streaks (vibices), or as discolored patches of various size
and shape (ecchymoses). In rare instances the effused blood raises the epidemiis and forms
what is sometimes termed a '"blood-blister" (ecchyraoraa). Cutaneous hemofrliages are
classed as traumatic and spontaneous.
PURPURA,
It is customary to describe three forms of purpura. In the most common form, or pur-
pura simplex, numerous small spots, of a bright purplish-red or claret color, appear suddenly
on the lower extremities, and in rare instances on other portions of the body. They occur
spontaneously, and are usually unaccompanied by any marked general symptoms. The
bright color changes in the course of a few days to a dull red, and after assuming the green-
ish and yellowish hues so frequently noted after an ordinary bruise, the spots gradually
disappear. Fresh extravasations often appear from time to time during the course of the
affection, and thus a contrast of colors may result. The spots commonly vary in size from
a pinhead to a small pea, are not at all elevated, and do not disappear on pressure. Some-
times they are slightly prominent at the outset, and sometimes large Livid patches develop.
(114)
X
A*
X
<
o
a:
D
Oh
PURPURA.
^Vht'D ihe liemorrhage takes place in or around the hair follicles a papular form of purpura
is developed \v^hich was formerly described as lichen lividus, and later by Hebra as purpura
papulosa.
Purpura hemorrhagica is a more aggravated form of the disease, in which large cutane-
ous extravasations are seen, not only on the skin, but also upon the mucous membranes.
Hemorrhages from the nose and gums occur, as also bloody stools and urine The constitu-
tional symptoms are marked, and the weakness resultuig from a continued loss of blood may
lead to a fatal termination.
Purpura (or peliosis) rheumatica is a peculiar affection (conveniently regarded at present
as a form of purp^dra), in which arthritic pains and fever precede an eruption of small
hemorrhagic macules upon both trunk and extremities. The disease usually runs a brief
course, although a repeated onset of fever and rheumatic pains, followed by cutaneous
hemorrhages, may protract it for months. It commonly attacks those who have a rheumatic
tendency, but are otherwise apparently well.
Diagnosis. The diagnosis of the simple and hemorrhagic forms of purpura is unat-
tended with difficulty. To the practiced eye the cutaneous lesions are characteristic, but
their hemorrhagic nature can be easily verified by noting the fact that they do not change in
color under the pressure of the finger, a circumstance which enables the tyro to distinguish
them from inflammatory lesions. Scorbutus, or sea-scurvy, is regarded as distinct from
purpura hemorrhagica, on account of its gradual development, the mai-ked swelling of the
gums, with loosening of the teeth, and the extreme debility, which are its prominent fea-
tures ; and from the fact that it occurs so frequently among sailors and those who cannot or
do not eat fresh vegetables. Purpura rheumatica may be readily mistaken for rheumatism
during the few days which precede the outbreak of the characteristic eruption. Tilbury
Pox regarded this form as simply an erythema, complicated by hemorrhage.
Treatment. The treatment of purpura consists chiefly in removing any cause which may
be ascertainable, and in enjoining absolute rest where the hemorrhages are severe and frequent.
Iron, ergot, the mineral acids and quinine are remedies of value, although too much reliance
may be placed upon their action, and too little thought given to the question of rest, proper
diet, and the hygienic influences which surround the patient. In mUd cases of iDurpura sim-
plex a moderate amount of exercise is rather advantageous than otherwise, and often the treat-
ment need not interfere with the daily duties of the patient. No remedy can be given to
hasten the disappearance of the hemorrhagic spots, but fuU doses of the tincture of the chlo-
ride of iron will usually check the development of new lesions, and improve the general con-
dition of the patient. In purpura rheumatica the patient usually recovers speedily under
good nursing, although an anodyne may be necessary to relieve pain, and a tonic of iron or
quinine prove serviceable at the close of the attack. In purpura hemorrhagica the patient
must be kept as quiet as possible. Ergot may be given by the mouth or by hypodermic
injection. For the latter purpose dissolve six centigrams (one grain) of ergotin in warm
water and glycerine. This, with the use of ice, will promptly control the hemorrhage from
(116)
DISEASES OF THE SEIN—HEMOIIBHAOIO.
ttie mucous membranes. A diet of fresli vegetables, which invariably produces such a bene-
ficial change in scorbutus (sea scurvy) is of no value in the treatment of purpura hemorrha-
gica.
SCORBUTUS.
Syii onym — Scurvy.
Under certain conditions, prominent among which is an insufficiency of proper food, a
train of symptoms occur to which the term scurvy is commonly applied. The affection is
characterized by general malnutrition, extreme prostration, difficult breathing, a swollen and
spongy condition of the gums and the occurrence of purpuric spots upon the skin. It com-
monly makes its appearance among sailors on long sea voyages, and in armies whose base of
supplies has been cut off. It also occurs in isolated cases among the poverty-stricken popu-
lation of many of our large cities. In this case it is sometimes spoken of as " land-scurvy,"
although its nature is identical with the affection so commonly associated with the sea.
The cause of scurvy has been the subject of considerable discussion. Some have attrili-
uted it to the eating of too much salt meat, of foods deficient in the salt of potash or in
phosphoric acid, etc., but it is now generally believed that a deficiency of the organic acids
in the food is the chief cause of the disease. It is certain that scurvy never develops among
any class of men who are plentifully supplied with fresh vegetables.
Treatment. The means required for the prevention of scurvy are evident from what
has been said of its cause. The same treatment will also cure the disease when once estab-
lished. But on shipboard, or in a besieged city, fresh vegetables are a remedy not always
attainable, and lemon juice has been found to constitute the best substitute. Dried vegeta-
bles, vinegar and citric acid are likewise of great value.
(116)
CHAPTER IV.
HYPERTROPHIC DISEASES.
The clasa of hypertrophic affections embraces those which are characterized by an in-
creased volume of one or more of the normal elements of the skin. In clinical appearance
and pathological importance they differ widely among each other. They are chronic in their
course, whether congenital or acquired, and the majority are but slightly amenable to treat-
ment.
Of the anomalies of pigmentation which form a division of this class, we have several
affections or phases of cutaneous disease which might, with propriety, be described under
one title, but time-honored custom has bestowed upon these separate forms of pigmentary
disease a number of names which cannot easUy be banished from dermatological Literature,
and hence it is convenient to describe them as distinct affections.
N-EVUS PIG-MENTOSITS.
Synonym — Pigmentary Mole.
A pigmentary nsevus is a discolored spot or freckle which usually appears in early life,
and persists without undergoing any marked change in size or color. This affection is often
spoken of as being congenital but is rarely so. The simplest form of nsevus pigmentosus is
a small pin-head sized brownish or blackish spot of so trifling a character that a number of
them may exist upon the skin of a person whose attention has never been directed to them,
and who would swear, Lf called upon to do so, that his skin was absolutely free from any
blemish. A pigmentary nsevus is round or elliptical in shape, perfectly smooth, and accom-
panied by Ao subjective sensation. It is, in short, a permanent freckle {Nosvus spilus). In
some cases this spot may be as large as the print of the thumb and similar in shape, while
in rare instances large portions of the trunk are the seat of a cii-cumscribed discoloration.
In certain cases the nsevus is elevated and somewhat Avarty in character {Ifcevtts verrucosus),
and very often is covered with a growth of hair {Ncbvus pilosus).
Treatment. A small, smooth nsevus may be removed from the face or hands, where it
is most apt to prove annoying, by applying carefully a drop of nitric acid or whatever wiU
produce the faintest possible cicatrix. The warty form of nsevus, which is sometimes pen-
dulous, can best be removed by knife or scissors.
(117)
DISEASES OF THE SKIN— HYP ERTROPHIO.
LENTIGO.
Synonyms — Ephelis — Freckles.
Freckles are small circumscribed yellowish or brownish discolorations of the skin, result-
ing from an abnormal deposition of pigment. They are usually of the size of a pin-head
and discrete, but in some cases they are somewhat larger and often so numerous that a dark
patch of considerable size is formed by their coalescence Upon the face, and particularly
upon the nose and cheeks, they are most frequently observed, but they are not uncommon
upon the backs of the hands and upon the neck and arms after habitual exposure of these
parts. In rare instances they occur upon the trunk, thighs and other covered portions of the
body. I have a photograph of one case in which they were abundant upon the abdomen and
penis. In this instance they were persistent, like pigmentary nsevi, but became much darker
and more striking in appearance every summer, though not exposed to the direct action of
the sunlight.
While the tendency of certain individuals to freckle is evident to the simplest obser\a-
tion, the reason of this fact is not readily discovered. Persons with a fair complexion and
reddish hair are far more likely to become freclded than those of the brunette type, and
among mulattoes the most marked cases of lentigo are to be found. This affection is rarely
if ever seen in infancy, but is common in early life. In old age pigmentary discolorations
are very common, especially upon the face and hands, but the freckles which come in sum-
mer and disappear in winter are not observed at this time of life.
Treatment. Since freckles do not affect the corium or true skin, but result from an
increased amount of coloring matter in the deepest layer of cells of the epidennis, it is evi-
dent that blistering or any kind of treatment which will remove the epidermis will remove
the frecklps. But the effect of this treatment is merely temporary, and with the renewal of
the epidermis a new deposition of pigment is likely to take place. The tendency to the for-
mation of frecldes in certain individuals cannot be remedied, but by avoiding exposure of
the skin to the direct rays of the sun in warm weather, the unsightly spots can be avoided
to a certain extent. Of the various tan and freckle lotions which have been recommended
highly and used extensively my o^vn experience wiU not allow me to speak in very high
praise. One of the following may prove of value as a placebo if it does no other good.
51.
Sulpho-carbolate of Zinc,
2 parts.
Oil of Lemon,
2 "
Absolute Alcohol, - -
10 "
Collodion, ....
to 100 "
M.
Shake and filter.
»
Carbonate of Potassium,
4 parts.
Chloride of Sodium,
. 2 "
Orange Flower Water to -
- 100 "
M.
(118)
CHLOASMA.
White recommends —
9 Chloride of Ammoniiun, - - • 1 part.
Cologne Water, 15 parts.
Water to 100 "
M.
According to Shoemaker the careful application of a small piece of the ointment of the
oleate of copper at night upon retiring will usually remove freckles. The oleate of copper
ointment should be prepared by dissolving the salt of oleate of copper in sufficient oleo-
palmitic acid to make a soft ointment.
CHLOASMA.
Synonym — Liver Spot.
Chloasma is a yellowish or brownish discoloration of the skin which commonly shows
itself in symmetrical patches upon the face. Some writers include under the name chlo-
asma a variety of i>igmentary affections resulting from Avidely different causes, distinguish-
ing them as idiopathic and symptomatic. The term has even been applied to one of the
parasitic affections. If we include under the term chloasma both the pigmentation of the
skin resulting from the application of a mustard plaster or from persistent scratching, and
that which is caused by the internal use of nitrate of silver, Addison's disease or the can-
cerous cachexia, there is no reason why it should not be made to cover lentigo and nsevus.
It were better if the term chloasma should be limited ia its application to that form of pig-
mentary disease which is commonly spoken of as chloasma uterinum, although it appears
in the majority of cases to have no more connection with the uterus than it has with the liver.
The patches of chloasma, limiting the signification of the term as above indicated, are
never small and distinct, rarely rounded or elliptical in shape, but usually irregular in form,
and with an ill-defined border. The color is not apt to be very pronounced, although in
summer the affection is much more noticeable than iu winter. The forehead and malar region
is the favorite seat of chloasma, and there may be a number of isolated patches of discolora-
tion or one large patch covering the upper portion of the face like a mask. This mask never
involves the whole of the skin of this region, but stops abruptly a short distance from the
scalp or the eyebrows, and thus leaves some normal skin which renders the patches more
unsightly by the contrast which the normal skin affords. The patches of chloasma are less
common upon the lower half of the face. Occasionally patches are to be found upon the
neck and trunk.
Females are commonly, but by no means exclusively, the subjects of chloasma, and
although it manifests a marked tendency in this sex to make its appearance dm-ing preg-
nancy, it is not infrequently met with among chUdless women and spinsters. Occurring
during the months of pregnancy it often disappears quickly after childbirth, but in many
(119)
DISEASES OF THE SKIN—RYPERTROPEIC.
cases it persists for years, thongh in a somewhat milder degree. It is never observed before
puberty and rarely continnes after tlie menopause.
Chloasma results from an abnormal accumulation of pigment in the epidermis, and the
nerves which should control the deposition of coloring matter evidently fail to do their duty
What the prime cause of the affection may be is difficult in most cases to determine. The
dependence of the discoloration upon uterine disease and menstrual irregularity is evident in
a small number of cases, but in a large majority it appears to me to be a groundless assump-
tion.
Diagnosis. The affection with which chloasma is most likely to be confounded is
leucoderma, the lesions of which are very apt to occur upon the face and neck. In this
affection there is an absence of pigment in circular or irregular patches with sometimes an
increased amount of pigment in the vicinity. In chloasma there are never any pale, milk-
white spots to be seen and the skin has merely a darkened or dirty appearance. With chro-
mophytosis a mistake ought not to occur, as the patches in this affection never appear upon
the face, and the surface of the affected skin, though sometimes apparently smooth like that
of chloasma, can always be made rough or mealy by simply scratching it with the fingernail
or any dull Instrument.
Argyiia, the bluish or slate color resulting from the internal use of nitrate of silver, dif-
fers from chloasma in the large extent of surface which is evenly discolored, and in the fact
that the hands as well as the face and neck are usually of a similar hue.
Treatment. In the treatment of pigmentary affections no brilliant results can be hoped
for. Indeed, it must be confessed that a result satisfactory to the patient is not frequently
attained. If the patient be pregnant she may be consoled by the hope, if not the surety, that
a little patient waiting will restore her former complexion. If she be a sufferer from dj's-
menorrhoea, treatment of this condition may be instituted with the hope, faint as it is, that
normal menstruation wUl be accompanied by a decrease of the discoloration. When general
treatment or special treatment for the removal of a hypothetical cause has failed to produce a
change in the complexion, the local measures already mentioned in connection with lentigo
may be employed. The proxide of hydrogen is the application which, in my hands, has pro-
duced the most favorable results. Care must be exercised in obtaining a sufficiently strong
preparation and in keeping the bol tie well corked and in a cool place. The affected skin
may be painted once or twice daUy. If a dark camel' s hair pencil be used the first effect
of the peroxide will be to whiten the hairs of the pencil. If this does not occur it is probable
the lotion has lost its strength and wiU produce little or no effect upon the skin.
CALLOSITAS.
A callosity is a hard and flattened tumor, but slightly elevated above the surface of the
skin. It is the result of an increased thickness of the epidermis, and occurs upon such por-
tii.n* of the body as are subjected to friction or intermittent pressure. The hands and feet
(120)
CLAVUS.
are the parts most frequently affected, and naturally those accustomed to manual labor or
who wear coarse, ill-fitting shoes are most likely to be affected. A thick and horn-like
epidermis is the normal covering of the heel and ball of the foot, and furnishes the natuiu]
protection which is usually supplemented by artificial plates of shoe-leather.
In walking the naturally callous portions of the sole should be a help rather than a
hindrance, but when as a result of high heels, short or Ul-fitting shoes or congenital talipes,
the foot is more or less turned or twisted, pressure is exerted upon a patch of soft epidermis
which gradually thickens, it is true, but often becomes inflamed and causes no little amount
of inconvenience and suffering.
CLAVUS.
Synonym — Corn.
A corn is a callosity of pecrdiar form which is commonly met with upon the toes. Being
the result of pressure it naturally forms upon the skin over the bony enlargement at the end
of the first phalanx, and most frequently upon the small toe. Corns also occur over the
extremities of the metatarsal bones, upon the soles of the feet and in rare instances upon the
hands. Upon the dorsal surface of the toes corns are dry and horny, while between the toes
they are kept constantly macerated and appear softer and white.
A hard corn is slightly elevated above the surface of the skin, rounded, flattened and
yellowish in hue. The under surface is more or less conical, which fact has given rise to
the common idea that a corn has I'oots.
Treatment. In the treatment of callous patches and corns, two objects should be kept
in view, the removal of the cause and the alleviation of the suffering. If arrow shoes are,
without doubt, the most frequent cause of corns, and the incalculable amount of distress
which they invariably produce in all civilized communities could only be avoided by defying
fashion and wearing stout moccasins, or shoes shaped like the feet. Possibly when we arrive
at the highest point of civilization our present style of foot covering will be abandoned, but
under the present condition of things we can only hope to secure from the modern shoema-
ker a somewhat less narrow shoe than he is in the habit of making. It is an excellent plan
for those suffering from corns and bunions to have a number of pairs on hand at all times so
that a frequent change can be made. This will usually obviate the continuous pressure upon
a given point and the resulting inflammation. To soften the epidermis various applications
may be advantageously employed. Prominent among these are glacial acetic acid and sali-
cylic acid. The former, if applied with care to the horny epidermis and not allowed to get
upon the healthy skin, wUl soften a painful corn or callosity so that the bearer can once more
walk with comfort, or so that it can be chiseled out of its bed with little or no pain.
Salicylic acid possesses a peculiar faculty for softening epidermic tissue, and is the chief
or sole ingredient of numerous com cures now in the market. A satui-ated solution in alco-
hol applied repeatedly will soften a corn so that it can be readily paired away or dug out
(121)
DISEASES OF THE SKIN— HYPERTROPHIC.
with a curette. An application of salicylic acid in collodion repeated every night will whiteii,
soften and often cause the disappearance of a troublesome com or callous patch in a few
weeks.
VERRUCA.
Synonym — Wart,
An ordinary wart (rerruca vulgaris) is a small, dry and homy tumor most commonly
seen upon the hands of children. These growths are multiple and vary in size from a pin-
head to a pea. Except when unusually large or inflamed they occasion little or no discom-
fort. They usually develop quickly, and having attained their full size, persist for an indefi-
nite time. They likewise disappear suddenly in some cases and are entirely gone before the
fact of their going is perceived.
The hands, and especially the fingers, are their favorite location, but they may also
occur upon the scalp, face and other parts. The common wart may present a somewhat
smooth, hard and flattened surface, or it may be considerably elevated above the level of the
skin, and present a well-marked digitate surface.
The so-called venereal warts are soft, moist papillary tumors, commonly met with upon
the genitals of both sexes. They are apt to be much larger than common warts and some-
times grow to large fungous masses resembling a cock's comb in appearance. Thej" are
usually of a bright red hue, sometimes dusky or bluish, and when exposed to the air the
surface becomes dry and blackened. In the male they are commonly found upon the mucous
surface of the prepuce, and upon the glans penis. In this location they often occasion a
phimosis, and their rapid increase in size soon distends the prepuce until it resembles a large
ball. When, in such a case, the prepuce is slit up and retracted it is not uncommon to find
that a portion of the warty mass has sloughed from its base and is ready to fall out when no
longer confined by the foreskin. The remaining masses, crowded and flattened by pressiu'e,
give the glans penis the appearance of a small red cauliflower. In the female these growths
are usually seen upon the fourchette and mucous surface of the labia. Around the anus in
both sexes these warts are often seen among a certain class of patients and frequently mista-
ken for an evidence of syphilis. The moist syphilitic papules which are common in this
locality in an early stage of the disease sometimes present a vegetating or fungous surface,
but are usually flattened, and hence called condylomata lata in distinction from the non-
syphilitic warts which are often spoken of as condylomata acuminata. Similar growths
may be met with in the umbilical cavity and even in the axillae, between the toes and wher-
ever the predisposing conditions of moisture and uncleanliness co-exist. They always
develop rapidly and under these conditions are not likely to disappear spontaneously like
the common warts.
The cause of warts is obscure, and a peculiar disposition to both varieties is observed in
many individuals. There is no doubt respecting the contagious nature of acuminate warts,
(122)
VERRUCA.
and it is quite probable that many cMldren contract ordinary warts from the hands of pi y
mates who are affected.
Diagnosis. A typical wart is always easily recognized, but there are certain affectio t
of the skin of a warty or papillomatous nature which the most experienced dermatologi^ s
often find difficult to name and classify. These are rare, however, and can be conveniently
termed Papilloma.
Treatment. In the treatment of ordinary warts a great variety of remedies have been
recommended, from the mildest charm to the severest caustic, and perhaps none of them are
absolutely valueless. Of the so-called charms employed by the ignorant, such as dipping the
hand in the rain water which has collected in a hollow stump, spitting on the warts successively
with an appropriate incantation, etc., etc., a great deal that is interesting might be written.
But the one point of practical importance to be noted is that some of these charms do ap pear
in certain cases to work wonders. Leaving out the untruthful and exaggerated reports of
their virtues and overlooking the numerous cases in which they utterly fail, there stUl
remain instances in the experience of many persons where a large crop of persistent warts
has disappeared suddenly after recourse to one of these vulgar methods of treatment. I
have never witnessed anything of the kind myself, but will admit that these supposed cures
may not be mere coincidences, but the indirect/ I'esult of the charm, the attention so firmly
directed to a portion of the body having induced a change in the nutritive process taking
place there.
Caustics will remove a wart if repeatedly applied, the dead portion being carefully pared
away before each application. Acid nitrate of mercury, nitric acid, chromic acid and caus-
tic' potassa have each been recommended and successfully used, but glacial acetic acid or a
saturated solution of salicylic acid is preferable if the application is to be made by the
patient. It is claimed that crystals of chloride of ammonium rubbed upon warts upon the
hands will cause their gradual disapearance. All I can say of this remedy is that I have
known it to fail.
Thuja occidentalis is a remedy of considerable repute in the treatment of both ordinary
and venereal warts. Given internally, I have waited in vain for any effect, but in the f oi-m of
a tincture applied once or twice daily, I have seen a beneficial action in a number of cases.
It gradually lessens the congestion in the case of accuminate warts, causes the epidermis to
become dry and friable and in time removes the growth in great part if not entirely. The
tincture or fluid extract used should be made from the fresh leaves of the plant and may be
applied pure or diluted with water.
The quickest way to remove warts, and in most cases the best, is to scrape them off with
a rather sharp curette. The procedure is attended with a little pain, but even a child can be
induced to have a number removed in this way at one sitting. The base of the wart should
be first scratched or cut with the edge of the curette, when one or two vigorous sweeps of
the instrument will quickly remove the growth and leave a circular, punched-out wound.
The bleeding which follows is usually slight, and can easily be checked with a bit of
(123)
DISEASES OF TUE SKIN.—RYPERTEOPEIC
styptic cotton or a drop of carbolic acid, which will also tend to remove any possibility of its
return.
The ligation of large warty masses may sometimes be advisable, but unless the base
whicli remains is thoroughly cauterized or scraped, they will speedily grow again. The cut-
ting of a wart is always a foolish precedure, as it only makes it bleed freely and cannot pos-
sibly destroy it. Large seed warts upon the fingers may be quickly and thoroughly removed
by grasping them between the blades of a stout pair of dressing forceps and twisting them
suddenly out of their bed. This, however, occasions more hemorrhage than the use of the
curette.
MOLLUSCUM.
Synonyms — M. Contagiosum — M. Epitheliale — Acne Molhmcum.
The term moUuscum has long been applied to two distinct affections, viz., one about to
be described {MoUuscum contagiosum of Bateman), and one which will be described later in
thLs work {Fibroma, or the Molloscum flbrosum of certain writers). The affection to which
the term molluscum should be limited consists of little soft tumors, varying in size from a
pin' s head to a small pea, mth a constricted base, a central depressed orifice and whitish,
cui'd}' contents. They are not of very infrequent occurrence among children, and are as in-
teresting to the dermatologist as they are hai-mless to the patient. The affection commonly
attacks children, and the face and neck is its most common seat. The tumors exhibit a
tendency in many cases to congregate about the eyes, and occasionally about the mouth. I
have met with them exceptionally upon the scalp, ears and tip of nose. In adults the
genital-s are the part usually affected, although the mollusca sometimes occur on nearly all
parts of the body.
Each individual tumor is of slow development and indefinite duration. It begins as a
pin-head sized whitish elevation in the epidermis, with a minute central depression, which
becomes more i)rominent as the growth increases in size. When it is as large as a hemp-seed
the summit becomes flattened, the base more or less constricted, the centre of the growth
appears whiter than the wall of the tumor, which is usually of normal skin-color, and lateral
pressure causes a whitish, cheesy substance to exude. Under the microscope this is found to
be composed mainly of peculiar round or oval bodies known as the "molluscum corpuscles."
The tumors have usually a waxy, transparent aspect, although, when they have attained the
size of a large pea, the walls are often traversed by fine blood-vessels, and present a pinkish
appearance. No pain or other subjective sensation accompanies the growth, which may
persist for a year or more, never getting larger than a large pea, and finally withering or un-
dergoing a process of destructive inflammation.
In a large proportion of cases the hands of the patient wUl be found to be the seat of
ordinary warts.
Tin- etiology of molluscum is obscure. Its occurrence in several members of one family,
(124)
MOLLUSC UM.
and the fact that it has been observed to aSect suddenly a number of children in a hospital
ward, have led to a belief in its contagious nature. But this is by no means proven. Al-
though the disease occurs with much greater frequency among the poorer classes, it cannot
be considered as the offspring of poverty and uncleanliness. Damp and crowded dwellino^
may favor its development, and I have known a number of cases to occur in such a locality.
HI health is not always a factor in its production, for while most of the molluscous children
I have exanuned were strumous or weakly, there have been Home upon whose faces not even
the dirt could conceal the glow of health.
Diagnosis. The diagnosis is very simple, the tumors being so peculiar ia appearance
that, when once seen and recognized, they could hardly be mistaken when met with a second
time. I have seen numerous mollusca upon the face of a young woman, which, on account
of their whitish, flattened summits and central depression, bore a striking resemblance,
when observed at a distance, to the umbilicated pustules of variola. A mistake in diagnosis,
however, could scarcely occur.
Fibromata, when small, might be mistaken for mollusca, and especially as the sebaceous
glands in the former tumors frequently contain an accumulation of sebum, which can be
pressed out in the form of cheesy threads. They do not present, however, a central depres-
sion, do not occur in groups, do not have the plump feeling of mollusca, but, on the other
hand, are apt to be quite flaccid, and finally, when multiple, as they usually are, they vary
considerably in size, and usually become much larger than mollusca.
Teeatment. The treatment of molluscum is simple, the object beiQg to remove the
excrescence and to excite as little inflammation as possible in so doing. "When the mollusca
are so situated as to admit of abscission, the most advisable plan of treatment is to shavt
them off with a razor, or a long, thin-bladed knife, at a level with the surrounding skin.
The hemorrhage occasioned scarcely amounts to more than a drop, and it is quickly checked
by touching the freshly-cut surface with nitrate of silver. When the mollusca are not
seated upon a projecting, or at least upon a convex part, but occur ia certain localities,
where, especially in the case of struggling children, a knife could not be handled with
safety, a pair of curved scissors may be used in its stead. For very small mollusca, nothing
more than slight cauterization is required to arrest their growth and to hasten their disap-
pearance. They may be bored very gently with a conical stick of nitrate of sUver, or touched
with a fine glass rod dipped Lu strong acetic acid. When a cluster of tumors have coalesced
and undergone a process of destructive inflammation, the hard crust should be removed by a
poultice or dressing of cosmoline, and a little balsam of Peru applied to heal the superficial
ulceration. When a molluscum, however large, is removed, no scar is left, imder ordinary
circumstances, since the growth is epidermic in character, and can scarcely be said to involve
the coriumor true skin. When an inflamed molluscum is scratched or irritated to the
degree of purulent secretion, a sUght pit may be expected to result.
(125)
DISEASES OF THE SKIN— HYPERTROPHIC.
CORNUA CUTANEA.
In medical literature we find many accounts of human horns springing from various
portions of the body. These cases create surprise and wonder at first thought, but when
we consider that the outer layer of the epidermis, together with the nails, is a natural gro\Arth
of homy character, we become far less surprised by these unnatural homy growths. The
favorite seat of horns may be said to be the head, although there is scarcely a portion of the
whole body which has been spared. They have been reported as occurring on the scalp,
forehead, temple, nose, cheek, lip, jaw, breast, back, pubes, glans penis, scrotum,
prseputium clitoridis, thigh, knee, leg, hand and foot. Though usually occurring in the aged,
they have been met with in young children. In size and shape they vary considerably, some
being short and stumpy, others conical, and many long, curving and somewhat spiral.
Rayer mentions the case of an old woman with a conoidal horn springing from the forehead,
which was six or seven inches in diameter at the base, and which projected six inches.
Nayler speaks of a horn ten inches in length, and curved like a ram's horn. The shorter
horns, with a rounded extremity, are usually thicker at the base than those of greater length.
The long ones are always curved when a few inches in length, and often twisted. The sur-
face is always rough, and usually ridged transversely. When of a marked homy character
the horn may present longitudinal striae, and show a tendency to split in this direction. The
color of a horn varies from a yellowish to a dark brown or blackish hue, and is lighter at the
apex than at the base. The consistence of the growth also varies, some horns being soft and
friable, and others quite dense. The outer portion is always harder than the inner. The
base of a horn, like the base or youngest i)ortion of a nail, is often surrounded vnth. a thin
layer of epidermis. "When removed, the horn presents a conical cup-like depression, which
fits over a fungoid mass projecting above the level of the skin ^Vhen cut across, it may be
found to be cylindrical or flattened from side to side. Microscopical examination shows it
to be composed chiefly of epidermic cells, usually arranged in a concentric manner. Tlie
horn may spring from the free surface of the skin, or originate in one of the larger se-
baceous follicles. It may therefore be regarded as being either an exaggerated wart, having
a soft, pulpy, papillomatous base, surmounted by a cone of dense epidermis, or as being a
dried and hardened sebaceous or epidermic mass, which derives its shape from being slowly
extruded from a sebaceous cyst. In some cases the nail, especially that of the great toe,
becomes greatly thickened and rounded and finally assumes the shape and other character-
istics of a horn.
Cutaneous horns develop slowly, and are painless when unirritated. The base may be-
come infiamed from injury done to it by violent movement of the growth. A horn may
continue to grow, whatever size it has attained, but the longer it is, the greater is its liability
to become accidentally knocked or tom off. When it falls in this way, or is merely cut off
on a level with the surrounding skin, the growth is reproduced, and a succession of horns
may occupy a given site. Not infrequently two horns take the place of a preceding one.
(126)
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Diagnosis. The diagnosis of a case is easy when the horn is present. Before the horn
has formed or after it has been removed the cutaneous lesion bears a resemblance to a nodule
or an ulcerated patch of lupus. The base from which it springs might be mistaken for an
epithelioma or malignant growth of some kind. On the lip, indeed, epithelioma has been
observed to follow a horny growth.
Treatment. The treatment called for in the case of a cutaneous horn consists in not
only removing the growth, but destroying the base from which it springs, in order to prevent
its reproduction. The horn itself, being frequently quite movable, can readily be torn from
the skin with a slight amount of violence, especially when the part has been previously
softened. The base should now be scraped with the curette, and cauterized lightly with
caustic potassa or the chloride of zinc. This will produce a radical cure, and leave but a
trifling scar in the place of the unsightly excrescence. When the horn springs from a dis-
tended follicle or cyst, extirpation of this with the horny growth is usually recommended.
ICHTHYOSIS.
Synonym — Fish-skin or Alligator disease.
Ichthyosis is a chronic disease of the skin, characterized by dryness and roughness. It
varies in severity from cases in which the abnormal condition of the skin is so slight as to
be perceptible to the touch rather than to the eye, to cases in which large polj'gonal scales
or blackened horny projections take the i)lace of the normal epidermis. This variable de-
gree of severity has led to a division of the disease into the forms to which the names xero-
derma, ichthyosis simplex, and ichthyosis hystrix have been applied. These terms are
convenient for descriptive purposes, but it should not be inferred that xeroderma and ichthy
osis are distinct affections. Nor is ichthyosis hystrix to be understood as meaning anything
but a peculiar form of ordinary ichthyosis.
In the mildest cases of the disease, very frequently observed in infants and young chil.
dren, there is a deficiency of the sebaceous secretion as well as of perspiration and a harsh
or mealy condition of the epidermis. The skin is a trifle darker than normal, and suggests
the idea of a lack of soap and water. In other cases, or in these same cases at a later period,
the epidermis becomes hypertrophied, and cracks in a characteristic manner. Small lozenge-
shaped or pentagonal scales result, which are slightly raised at their margins. In a more
severe or further advanced condition these hypertrophied epidermic plates become darker in
color, and assume a yellowish or greenish hue, while the furrows between them appear like
a network of white interlacing lines. The plates, though horny and sometimes glistening,
are never found lapping one over another, as might possibly be inferred from the name of
the disease or its common synonym of "fish-skin disease." In cases of unusual severity
one or more patches of skin may become covered with black papillary projections, presentiug
an appearance which is suggestive of the bark of a tree. These patches are similar to those
(127)
DISEASES OF THE SKIN.—EYPERTROPEW.
warty growths whicli appear upon the skin in elephantiasis. When these papillary projec-
tions, which are always thickly crowded together and usually ilattened, become elongated
and pointed, the term ichthyosis hystrix has been applied to the condition, from the fancied
resemblance of the spines to the quills of a porcupine. Cases presenting this form of the
disease have been on exhibition as "Porcupine men."
Dr. L. P. Yandell has reported {Louisville Med. News, 1878,) an interesting case of ich-
thyosis, which was on public exhibition as the "Man-fish of Tennessee." Represented a
magnificent example of the form of the disease which has been called Ichthyosis serpentina,
the resemblance of his skin to the skin of a boa-constrictor being almost perfect. About his
joints the skin was loose and wrinkled. Upon the belly and limbs the scales were large and
suggestive of the skin of a lizard or alligator. The cuticle was everywhere dry and hard
and there was no perspiration. The man was fifty years of age, but being shrunken and
withered he appeared like a very old man. The skin of the face was red and shining and
tightly drawn about the cheeks, pulling the lower lids do^^-n to such an extent as to perfectly
evert them and making a horrid case of Ectropion. The fingers and toes seemed shorter
than natural and the separation between them extended much further down than usual, sug-
gesting a webbed condition. He was the father of several children, none of whom inherited
the disease.
Another striking case of the aflEection was lately on exhibition in this city under the name
of the "Alligator Boy." Two excellent colored lithographs of this child will be found in
the Journal of Cutaneous and Venereal Diseases (April, 1884). At the Skin Clinic of the
CoUege of the Physicians and Surgeons, the following brief notes were taken :
At birth the child weighed four and one-half pounds and presented an ichthyotic con-
dition, which has since increased in severity. When about a year old, the frontal epidermis
split vertically in the centre of the forehead and was cast off in two lateral pieces. The
hands at this time "looked like those of a ninety-year old man." The boy had never had
any of the acute exanthemata, or severe illness of any sort ; and in spite of the fact of his
spending the most of his time in the close atmosphere of the show room, he was said to be
far less delicate than one would judge by his appearance. The muscles of the lower extrem-
ities were not at all developed, and he was scarcely able to stand alone. By means of his
arms, he would creep across the floor quite readily, and, according to the father's statement,
could not only swim like his namesake, but had an uncontrollable desire to get into the water
whenever an opportunity offered. He had a good appetite, and was especially fond of fish,
oysters, and the whites of eggs. He liked fruit, but ate no meat, and I was assured that his
bowels rarely moved oftener than once in two weeks.
The eruption, contrary to the rule in ichthyosis, was most marked upon the trunk, the
epidermis being broken, by the movements of the body, into polygonal horny plates of vary-
ing size, and of a dirty yellowish hue. In the intervening fissures, the pinkish color of the
deeper skin was apparent. The scalp and forehead were also affected in a marked degree.
Tlie rest of the face was free from scales, save a slight mealy o'7ndition around the nose and
(128)
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ICHTHYOSIS.
moutli, and the cheeks were as smooth and soft as those of any child. The arms were but
slightly affected, and the fore-anns, especially upon the extensor aspect, were almost natural
in appearance. The legs also were almost free from scales. The parents stated that in
winter the sMn upon the trunk was smooth, though horny in character. In the spring this
homy integument was wont to crack and present the characteristic "alligator" appearance,
while the hair of the head was almost entirely shed. In the summer the scales would grad-
ually lessen and the skin become much softer, though by no means normal.
This boy was bom in Montreal, in May, 1879, and Dr F. Kennedy, who officiated at his
dM)ut, has kindly furnished me with the following information. The mother was a primi-
para, and claimed that it was impossible for her to have been more than eight months preg
nant at the birth of her chUd. At four and one-half months (according to her statement to
me), she was frightened at the sight of an alligator, and, a few weeks later, by seeing a dog
ia a fit. A tedious and irregular labor was followed by natural delivery. At birth, the child
presented a most extraordinary appearance. The skin was thicldy covered -s^-ith vernix
caseosa, and, when washed, the surface was as smooth as if polished, and of a deep red
color. In fact, the surface had the appearance of being thickly varnished. There were
very few fissures noticeable, and so strong was the coating that it was impossible for the
child to make use of its facial muscles in its efforts to cry or suck. Its limbs were also res-
tricted in their movements. After a few days, fissures occurred more especially along the
facial lines. On the forehead were two large scales separated along the median line. On
the eyelids, cheeks, and around the mouth, armor-like scales were formed. On the back the
scales were very thick. There was no healthy skin, as the whole surface was more or less
covered with scales. The skin was thoroiaghly smeared with cod-liver oil, and the same,
with iodide of iron, was given internally. Under this treatment considerable improvement
was obtained. About the second week the scales loosened and peeled off, and about the fifth
week, the skin, with the exception of the face, had become soft and pliable, though still of
a deep red color and shiny.
The above case may be regarded as a connecting link, in point of severity, between
ordinary cases of congenital ichthyosis and certain cases which have been reported by Kyber,
Wheelock and others, as diffused congenital keratoma. In these cases, the integument
appears as one immense homy plate, of a dirty yellowish hue, or if this is broken during the
delivery of the child, the fissures formed reveal a bright red underlying skin. These cases
usually die at birth, or shortly after, and may be regarded as the most severe form of con-
genital ichthyosis.
Ichthyosis affects the greater portion of the skin. The palms and soles are always free
from scales, although the epidermis may be considerably thickened. The flexures of the
joints are usually devoid of scales, although abnormal dryness of the skin is always present.
Around the elbows and knees the epidermis is broken up into smaller plates, and numerous
elliptical wrinkles or folds of skin occupy these parts. The disease usually begins in infancy
and never in adult Ufe. In the majority of cases the mUd or xerodermatous form tends to
(129)
DISEASES OF TEE SRIN—ETFERTROPHIO.
remain through life, while in some instances the affection increases in severity from year to
year. It is sometimes hereditary. Two or more children in one family may be affected,
while others in the same family show no tendency whatever to the affection. It is attended
with little or no discomfort beyond the consciousness, on the part of the patient, that his
skin is not what it should be, and it exerts no influence on the patient' s general health.
Wild cases are often temporarily cured in hot weather, when the perspii'atory glands are
active, and even the most aggravated cases are considerably better in summer than in ^vinter.
In the latter season ichthyotic patients usually suffer considerably from the cold, and when
exposed to high winds the face and hands are unusually prone to become chapped and
painful.
Diagnosis. The diagnosis of the disease is easy when its extensive distribution ove>"
the body, the absence of redness and itching and its chronicity are taken into account.
Pityriasis simplex is the only affection to which it bears any resemblance, but in pityriasis
the skin is not so generally affected, there is hypersemia beneath the scales, and these are
constantly falling, or are easily rubbed off, while in ichthyosis there is no hyperjemia, and
the scales remain upon the skin.
Treatment. The treatment of ichthyosis, or at least its cure, is not easy. The skin may
be made quite smooth by appropriate applications, but as soon as these are laid aside, the
roughening and scaling tend quickly to reappear. Inunction is the chief remedy in the
treatment of mild cases. Cosmoline, vaseline, benzoated lard, almond, linseed and cod-liver
oils are useful, and as each accomplishes the object in view, viz., the lubrication of the pre-
tematurally dry skin, it matters little which one is selected. Balmanno Squire thinks tliat
glycerine diluted with three times its quantity of water is more effectual than oil in keeping
the skin in good condition.
In severe cases, where the epidermic plates are thick and homy, inunction may still be
advantageously employed, but greater dependence must now be placed upon soap frictions
and constant bathing. Some patches on the extensor surface of the extremities may be so
hard as to require blistering. The Turkish bath renders excellent service in all cases of ich-
thyosis. The profuse sweating is useful, as is shown by the improvement which naturally
takes place in hot weather, and the shampooing removes the superfluous epidermis. The
body should be thoroughly anointed after each bath. Jaborandi has been given internally
in this affection, and has produced a rapid improvement in the condition of the skin, but
there are objections to the use, and the Turkish bath is to be preferred.
KERATOSIS PILARIS.
Synonym — Lichen Pilaris.
An accumulation of epidermic cells in the hair follicles produces numerous fine papules
upon the surface of the skin, and constitutes the affection kno\vn as keratosis pilaris. Ordi-
narily these are dry, whitish horny elevations, thicldy crowded together, and giving the skin
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MO RFHCEA.-^SCLERO DERMA.
a rough and harsh appearance, but frequently they become inflamed at their base and the
skin is then studded with small pin-head sized, conical red papules, each of these is usually
perforated by a fine lanugo hair, showing the lesion to originate within the follicles.
The affection is also noticed on the extensor aspect of the extremities, especially on the
forearms below the elbows. Frequently the outer aspect of the thighs and buttocks are its
seat.
It usiially causes no special inconvenience and often exists for years. In certain cases
however, the affection becomes quite marked upon the extremities, is accompanied by more
or less itching and thus induces the patient to seek medical aid.
The cause of the affection is sometimes a lack of cleanliness or undue attention to the
hygiene of the skin. This may be the case when there is a simple accumulation of epidermis
in the follicles, but often there is an excessive growth of the epidermis which frequent ablu-
tions do not check. This is almost invariably associated with a general dryness of the skin.
The affection is met with in youth and middle age, and is perhaps a little more frequent
among females.
Teeatjient. In mild cases of keratosis pilaris daily friction with green soap will suf-
fice to remove the horny prominences and leave the skin comparatively smooth. In cases
where a large extent of surface is involved frequent warm baths containing potash or soda,
and daily inunction with oil or fluid cosmoline are admirable. The general health should be
improved as far as possible, and when a sluggish circulation and inactivity of the sweat
glands are noticed the Turkish bath is the best remedy that can be prescribed
MORPHCE A. -SCLERODERMA .
It is convenient to speak of morphoea and scleroderma together, as there is a kinship
between the two affections, and, according to several writers, a pathological identity. Bui
whether they are forms or stages of the same disease or not, a clinical differentiation is gen-
erally easy, and until a fuller knowledge of their nature has been acquired, it appears advisa-
ble to retain both terms in use.
Morphoea is a circumscribed affection. When first noticed there are usually one or more
round or oval whitish patches of skin, with a faintly marked border of a darker hue. "When
multiple, these patches vary in size, and are usually distributed along the course of a nerve.
They increase but slowly in size, and assume an alabaster whiteness or a dull creamy tint,
which has been aptly compared to the color of an old billiard ball. They are seldom raised,
but, on the contrary, they may be slightly depressed below the surface of the skin, and
appear atrophic in character. The surface may be smooth and waxy, or roughened by nu-
merous fine wrinldes, which give to it a peculiar shriveled appearance. Sometimes a patch
is quite firm to the touch, although the hardness, when present, is always superficial. On
the other hand, it may differ little to the touch from the surrounding normal sldn. The nar-
row border fi-equently assumes a dull red or lilac hue, and constitutes a conspicuous feature
(131)
DISEASES OF THE SKIN—ETPERTROPHIC.
of the affection. Dark macules of a similar tint are often noted as preceding the develop-
ment of the smal. white patches. The affection is most common on the extremities, though
met with on tlie neck and trunk. There is no pain or discomfort produced by the presence
of the patches, and after a lapse of years they may tend to disappear spontaneously.
Scleroderma is a diffused induration of a tract of skin and its subjacent connective tissue.
The affected part at first becomes stiff, and later assumes a certain density and tension,
which is well expressed by the term "hide-bound." The skin itself presents no lesions to
the eye, save in some cases a decided pigmentation. The affected part may appear shrunken,
but the peculiarity of the affection is best revealed to the touch. There is usually no
margin to a patch of scleroderma. The hardness gradually shades off into the surrounding
normal skin. Large tracts of skin are often involved by the disease — the whole side of a
limb, for example. Like morphoea, it progresses slowly, lasts indefinitely, and in rare in
stances subsides spontaneously.
From the above brief description a striking difference is seen to exist between tjT)ical
cases of morphoea and scleroderma. But in some cases the patient presents lesions charac-
teristic of each affection. The diagnosis is consequently uncertain, and the conviction is
foscered that the two affections are identical in nature. Both morphoea and scleroderma
h*" ve been observed more frequently in women than in men. Cases occur infrequently in
0^ ildhood. No known cause exists, and the patient affected may in other respects appear in
' verage health.
Diagnosis. Morphoea, in its incipient stage, is to be distinguished from scleroderma,
which it resembles. The marked change in the character of the skin, apart from its mere
loss of pigment, and the partial ansethesia which usually exists, are points of diagnostic
value. The whitish anjesthetic macules which sometimes occur in leprosy resemble morphoea,
but their nature is generally revealed by the co-existing indications of the leprous diathesis.
Scleroderma can hardly be confounded with other cutaneous affections. It should be re-
marked, however, that there exists an acute affection of the skin, in which hardening of the
integument takes place rapidly over a large portion of the body, and disappears in a short
time. This must be distinguished from scleroderma, and may be conveniently called scleri-
nsis or sclerema, the latter of which terms has been usually applied to a similar affection
occurring in infants (Sclerema neonatorum).
Treatment. Little benefit is to be expected from treatment in cases of morphoea or
scleroderma. Under arsenic internally and the local application of the constant galvanic
current there seems to be the best prospect of achieving success. The use of the galvanic
battery in cases of scleroderma has been followed by very good results. The progress of
these affections Ls slow and the prognosis is uncertain. A marked improvement, if not a
perfect cure, is always a possibility, and since the local condition is more or less dependent
upon the general health of the patient, nothing in the shape of tonic and hygienic treatment
should be neglected.
(132)
ID
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ELEPRANTIAS18.
ELEPHANTIASIS.
Synonyms — Lepra Arabmn — Barbadoes Leg.
Elephantiasis is a disease wMch is entirely distinct from leprosy. Hitherto much confu-
sion has been occasioned by the use of the terms Elephantiasis Arabum to designate the dis-
ease under consideration, and Elephantiasis Grrgecorum to designate leprosy. These qualify-
ing adjectives have now been pretty generally discarded in this country, and while the term
lepra is applied to leprosy, the term elephantiasis is employed solely in connection with the
elephantine disease.
This disease consists in a hypertrophic growth of skin and sab-cutaneous tissue, and
affects chiefly the lower extremities and genitals. The leg and foot are most frequently
attacked. It is unusual for the disease to extend above the knee, and extremely rare for both
lower extremities to be wholly affected, as in the remarkable case portrayed in the illustra-
tion. Cases have been reported of the disease occurring upon the cheeks, breast and upper
extremities. Fibromatous tumors and that peculiar relaxed condition of the skin known as
Dermatolysis or Cutis pendula may occur upon those parts and assume elephantine propor-
tions, but they are to be carefully distinguished from true elephantiasis.
The disease is chronic in its course, does not affect the health in any marked degree, and
the patient suffers principally from interference with locomotion, depending iipon the weight
of the affected limb. It is met with in all parts of the world, but abounds in tropical cli-
mates, where it attacks by preference those whose constitutions have been impaired by im-
proper diet, excessive exposure and other causes. In the West Indies it is so common that
Barbadoes Leg has come to be a well-known synonym.
The disease is intimately connected with conditions which produce obstruction of the
lymphatics. (Edema plays a most important part in the production and development of the
disease, and recurrent inflammatory attacks of an erysipelatous nature characterize its prog-
ress. Each attack leaves the skin more swollen and harder, and the attacks continue at a
variable interval until the part affected has attained an immoderate size. The scrotum, for
instance, may hang nearly to the floor and weigh upwards of a hundred pounds. In the
female the labia and clitoris may be similarly affected. The skin of an affected leg is dark-
ened in color and either smooth and oedematous or fissured and scaly. Its sensibility is less-
ened by reason of the great thickening, but there are no anaesthetic patches as in leprosy. In
severe cases portions of skin become pendulous and deep creases are formed between them.
Upon the dorsum of the foot and anterior aspect of the leg it is not uncommon for the skin
to present a verrucous surface, covered with dry and blackened papillary elevations. Eczema
often appears upon the surface of the skin, and fissures occur at the bottom of the furrows.
Slight ulceration is present in many cases, and from the denuded patches a large quantity of
lymph is poured out. Sloughing may take place, especially when the strength has failed
and the patient is unable to leave the bed.
(133)
DISEASES OF THE SKIN—HYFERTROPHIG.
Diagnosis. Elephantiasis is neither contagious nor transmitted through hereditai y intlu .
ences. Its causes are obscure, but are doubtless connected mth the patient' s manner of living.
Malaria has been cited as a cause, but proof is lacking as to its influence. Varicose veins,
cicatrices, gummy deposits, bone callus and other local conditions inducing obstruction of the
venous and lymphatic circulation have been alleged to act as exciting causes. A very interes-
ing and plausible theory has been advanced that the disease is of parasitic origin, and that
furthermore, the mosquito is responsible for its existence. Dr. Manson, a British surgeon
resident in China, has discovered the. filar ia sanguinis in the blood of elephantiasic patients,
as also in the blood of patients affected by the so-called lymph-scrotum and chyluria. He
believes, with others, that this parasite has its habitat in the lymphatics, and by causing ob-
struction and distal fullness of these vessels, gives rise to elephantiasis. As in the case of
tape-worm ova, the immature ./^'arz« can only become developed outside of the human body,
and the mosquito is accused of being their intermediate host. In the stomach of this insect
the undeveloped tilaria is supposed to undergo a metamorphosis, and being discharged with
the young of the mosquito upon the water, finds its way into human lymphatics and occa-
sions elephantiasis.
Treatment. The treatment of this disease, though often gratifying, is not always
attended with the desired success. In the early stage, rest, poulticing and other antiphlo-
gistic remedies should be employed during the erysipelatous attacks. Later, bandaging is of
service, as it tends to lessen, though seldom permanently, the size of the leg. Hebra recom-
mended elevation of the limb and inunction of mercurial ointment. Compression and liga-
tion of the femoral artery have been practiced in a number of cases with partial success. The
improvement which follows this method of treatment is due to the removal of arterial pres-
sure, which interferes with the functions of the lymphatics. This pressure being removed,
a rapid absorption of the effused serum often takes place, and in some cases the decrease of
the infiltration is permanent. When the genitals are affected in a marked degree the knife
is the remedy most in vogue, and by its skillful use most brilliant results have been achieved.
ROSACEA.
Synonyms — Acne Rosacea — Gutta Rotacea,
Rosacea is a chronic disease of the middle period of life, occurring upon the face, and
resulting from a dilatation of blood-vessels and an increased growth of connective tissue.
Its chief features are redness and a tendency to the development of tubercles and pustules.
The affection has been described by writers on dermatology as a form of acne, and even those
who have believed it to be a distinct affection have generally employed the term Acne- Rosa-
cea. Some writers, in order to distinguish the affection from acne, as should be done, have
employed the old but expressive term Gutta Rosea or Gutta Rosacea. Recently rosacea has
been disjoined from acne in name as well as in nature, and this usage will doubtless tend to
dissipate the erroneous idea that they are forms of the same disease.
(134)
BOSA CEA.
Rosacea is common in both sexes and is most frequently met with oetween the ages of
thirty and fifty. Its site is characteristic. If the face were mapped out into vertical thirds
the middle section would include nearly all cases of rosacea. The parts most frequently
affected are those portions of the cheeks below the infra-orbital ridges. In severe cases a
fiery triangle may be seen on either cheek, lying between this ridge and the zygomatic minor
and labio-nasal muscles. A milder form of the disease often exists upon the central portion
of the forehead, just above the bridge of the nose, and at a shoi-t distance from the angles of
the mouth isolated rosy drops are frequently observed.
The simplest form of rosacea is that which appears in the form of dull red macules or
slightly elevated papules, resulting from chronic congestion or dilatation of the superficial
vascular plexus around the mouth of a follicle. These "rosy drops" sometimes present a
central point of a somewhat darker hue, more elevated and at times surmounted by a scale
or the thin crust of a minute pustule. The confluence of these circular "drops" forms a
purplish-red patch, presenting a swollen and uneven surface dotted with patulous follicles
and somewhat resembling the skin of an orange in texture. As the disease advances the
patch becomes studded with tubercles which usually tend to suppuration. The rounded
summit of the tubercle assumes a yellowish- white appearance and a minute superficial drop
of pus, evacuated when the patient is washing or mping the face, gives place to a thin, dark
colored crust. In many of the tubercles a more decided form of suppuration occurs and in
a case of long standing numerous hemispherical pustules or abscesses are accordingly present.
These pustules are not of glandular origin, as in acne, and may be easily distinguished from
true acne pustules by their rounded summits and the absence of a central comedo. Similar
pustules or small superficial abscesses not unfrequently occur in acne, especially in the indu-
rated form, and are not connected with the sebaceous glands.
Dilatation of the superficial blood-vessels, though commonly occurring in rosacea, is not
an essential element of the disease. Where the condition is marked, as it often is upon the
wings of the nose, constituting the most striking feature of the affection, the term Rosacea
caricosa has been employed.
The most remarkable form of the disease is that Icnown as Rosacea hyperrrophica. It
IS a late stage of the affection and occurs chiefly on the nose. The tumid or luTJipy condition
of the skin which is characteristic of the disease in its common form becomes exaggerated to
such an extent that the nose assumes astonishing proportions. A number of tumors project
from the sides or tip, varying in size from a large pea to a small egg, and frequently become
pedunculated. The nose may attain the size of the fist, and either partiaUj- obstruct vision
or hang down in front of the mouth. This condition is fortunately so rare as to constitute a
dermatological curiosity.
Treatment. Rosacea resembles acne, in being largely dependent upon disturbance of
gastric and uterine functions. The treatment in most cases consists of a combination ol
internal and local remedies. To achieve success with the former we must ferret out aU pre-
disposing and exciting causes. Abnormal states of internal organs must be rectified. Inju
(135)
J)Ii' EASES OF TUE SKIN.— RYPERTRO PEW.
rious habits must be abandoned by tlie patient and strict attention paid to hygienic rules.
To derive benefit from local applications it is necessary to determine the amount of stimula-
tion required by each individual case. In mild cases, where there is much irritability and
little thickening of the skin, the following lotion may be used while the cure is being effected
by internal treatment :
9 Borate of Soda, 6 parts.
Glycerine, 5 "
Rose Water to . . . . loo "
M.
Where more stimulation is desired the following may be applied to the affected part at
night and the powder allowed to remain until morning.
]^ Sublimed Sulphur, - - - - 10 parts.
Spirit of Lavender, - - - - 90 "
M. Shake before using.
When there is marked infiltration of the skin a course of nightly frictions with green
soap is of great value. Hard nodules upon the cheeks which remain red for a long time
without suppuration can be effectually treated by electricity, the constant current being used
for this purpose. Dilated blood vessels may be well scarified, and after the blood has ceased
flowing a thick coating of elastic collodion painted over them.
A still better mode of destroying them is to insert a fine needle connected with the zinc
element of a galvanic battery, and complete the circuit by touching the Jieighboring skin
with a sponge tipped electrode connected with the carbon element. In the hypertrophic
form of the disease surgical treatment is indispensable.
HYPERTRICHOSIS.
Synonyms — Trichauxesis — Hirsuties.
An abnormal increase in the growth of hair may be conveniently divided, according to
Beigel, into three classes.
In the first class we have those cases in which the naturally hairy parts, e. g. , the scalp
and lower portion of the face, become the seat of a growth of hair of extreme length.
Many readers may have seen on exhibition in this country several women whose luxuriant
growth of hair has nearly or quite reached the floor, and a man whose long sandy beard
would have to be lifted to prevent his treading upon it. A number of such cases are on
record, as also one of a woman whose pubic hair was several feet in length.
In the second class of cases are those in which the fine lanugo hairs which are present
over the greater portion of the skin, become large and moderately long, and transform a man
into a hairy animal. This overgro\vth of hair may be congenital or acquired. Medical litera-
ture records numerous instances of children who have been born with a hairy skin, and the
(136)
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R YPERTRICR0SI8.
circumstance has usually been attributed to some maternal impression occurring during preg
nancy. In certain cases this disposition to hirsuties has been hereditary and transmitted
through several generations, and it is noticeable that the excessive growth of hair has fre-
quently been associated with a defective development of the teeth. As an acquired condition
a certain degree of hairiness is often noted in adolescence and adult Ufe. While the trunk
and limbs of some men appear quite hairless at a short distance, others rival Esau in the
abundant growth of hair upon the breast and elsewhere. This variation appears to have no
more connection with the general health and strength than has the varying complexion of
the skin. A temporary growth of hair over the body has been noted as occurring during
convalescence from fever, and the local increase of growth following the congestion of the
skin in the neighborhood of an ulcer is very common.
To this class of cases belong the hairy moles (Nsevus pilosas), which are always congeni-
tal when of large size. In this affection the lanugo hairs over a circumscribed patch of skin
are abnormally developed and associated with an increased deposition of pigment.
The third class of cases of hypertrichosis includes the women and children who present
an unusual growth of hair upon those parts which in men are naturally bearded. Cases of
young children who have had hair upon their face or breast have been reported, but they are
extremely rare. The growth of hair upon the female face, on the other hand, is a deformity
which is very frequently observed. Few physicians have an adequate idea of its prevalence.
In nearly every "museum of living curiosities" a bearded woman figures as one of the
chief attractions. There are at least a half dozen of this class now on exhibition though-
out the country. Of the number of ladies in private life who endeavor by artifice of various
kinds to conceal the unpleasant fact that they have or might have a beard, it would be very
difficult to form an estimate. I have no doubt that there are many hundreds of such cases.
I speak now merely of those who might raise a thick and long growth of hair which would
deserve the name of beard. Of those who have a comparatively moderate growth of hair
upon the face, the number is beyond computation. The upper lip is most frequently affected
to a slight extent, but the most disfiguring growth occurs upon the sides of the chin. The
hairiness may be strictly limited to these parts, but in many cases it is seen also upon the
cheeks and sub-maxillary region.
The cause of hypertrichosis is always obscure, and perhaps no more satisfactory explana-
tion can be given of its occurrence, whether in the congenital or acquired form, than the asser-
tion that it is a " freak of nature." I have sought diligently for the cause of facial hairiness in
females and have endeavored to find some characteristic common to all of my patients, but
in vain. Some are in fine physical condition while others are debilitated. Some are ex-
tremely nervous. Some are not so in the slightest degree. Some are stout and others are
thin. Some are of dark and others of light complexion. Some are maidens ranging from
fifteen to fifty years of age, while of others, who are married, some have children and some
have none. The common idea that the growth of a beard in a female is usually associated
with masculine traits of character is certainly not founded upon fact, for most of my patients
(137)
DISEASES OF THE SKIN—HTFERTROPHIC.
have presented the very highest type of feminine refinement. That facial hairiness is depend-
ent upon a malformation or imperfect development of the reproductive organs, as some have
claimed, appears to me to be very doubtful. It is certain that an intimate relation between
these two conditions has not been satisfactorily proven, save in a few exceptional cases.
The relation of facial hairiness in females to derangement of the nervous system is
without doubt a much more intimate one. The depressed mental condition which is a
striking feature of many cases, and often those in which the hypertrichosis is very slight, I
believe it to be not only the result of the annoying growth, but a symptom of general ner-
vous disease upon which the hairiness in all probability depends.
The tendency to the growth of a beard in females, like the congenital form of hypertri-
chosis, is often found to be hereditary. In a large number of cases I have been surprised to
find upon inquiry that the patient resembles her father in appearance, and in some cases has
apparently inherited the affection from a paternal grandmother. The paternal resemblance
in these cases may be taken as the rule to which there are few exceptions.
Treatment. The only cases of hypertrichosis which the physician is likely to be called
upon to treat are those in which the gro^vth of hair occurs upon the female face. The depil-
atory pastes and powders which have been long in use have little if any more effect than the
application of the razor. Neither will permanently eradicate the growth. The injection of
acid, introduction of hot needles and similar procedures wiU often destroy the hairs, but not
without leaving scars which are even more disfiguring. The use of electrolysis in the man-
ner first suggested by Hardaway, is the best and the only method by which hair can be
permanently removed without injury to the skin. The operation has been gradually perfected
in this country dxiring the past few years, and constitutes one of the most brilliant achieve-
ments of dermatology.
In the destruction of the hairs by electrolysis a sixteen or twenty cell battery is neces-
sary, with a fine needle attached to the negative cord. This is inserted carefully into the
follicle by the side of the hair, and the circuit completed by having the patient grasp a moist
sponge or electrode attached to the positive cord. Electrolytic action now takes place and
destroys the tissue which produces the hair. A stinging sensation is experienced by the
patient, the hair becomes loosened in the course of from ten to thirty seconds and may be
removed by the gentlest traction of a pair of forceps.
ONYCHAUXIS.
Bj/noni/m — Hypertrophy of the naU.
An increased growth of nail substance may produce a uniform thickening of the nail or,
as is more frequently the case, a number of ridges, lumps and other surface irregularities.
This condition is most frequently observed in the smaller toe nails, which, instead of pre
senting the appearace of smooth, slightly curving, homy patches, become roughened, thick-
ened and distorted. These deformed nails, when allowed to grow, usually form spiral or
(138)
ONTCHA axis.
conical masses, witli numerous transverse ridges. The finger nails are rarely, if ever, affected
in a similar manner. When a normal finger nail is allowed to grow without being cut it
evinces a marked tendency to twist and roU when it has attained the length of a few inches,
but this condition is not included under hypertrophy of the nail.
An abnormal thickening of the nail substance is commonly the result of a diseased ma-
trix. A constant irritation resulting from pressure or chronic inflammation increases the
functional activity of this portion of the skin. With the subsidence of the irritation, a
healthy nail substance may again be formed, but in all cases where the matrix has been
injured beyond hope of restoration to a normal condition the deformed nail wiU always con-
tinue to grow.
A peculiar form of affection resulting from h3rpertrophy of the bed of the naU is some-
times called onychogryphosis. The normally thin layer of epidermis immediately beneath
the nail substance increases in thickness until it forms a dry mass which raises up the nail
from the bed.
Treatment. The thickened and roughened nail can be somewhat improved in appear-
ance by the application of glacial acetic acid and repeated scraping, but radical treatment
must be adapted to the condition of the matrix. Strapping the nail with adhesive strips or
enveloping it in a tightly-fitting elastic cot has been successfully tried. The accumulation of
homy epidermis beneath the nail can be softened by means of a wooden tooth-pick dipped
in a strong potash solution, and dug out with a fine-bladed penknife. A one per cent, solu-
tion of corrosiTe sublimate should then be frequently applied beneath the nalL
(189)
CHAPTER Y.
ATROPHIC DISEASES.
The class of atrophic affections includes those in which one or more of the elements of
the skin are absent, diminished, or the seat of a degenerate process. As in the preceding
class, some of the affections involve the skin proper, some lead to an anomalous pigmenta-
tion, while others are characterized by an impaired nutrition of the hair and naUs.
ALBINISMUS.
A congenital absence of pigment in the skin is termed albinismus. This may be com-
plete or partial. Among the lower animals the condition is so common as not to excite
attention. The white rabbits, white mice and white birds of this climate are all instances of
albinism, and in the polar regions an absence of pigment is the rule rather than the excep-
tion. This being the case it seems strange that in the human race albinism should occur
with perhaps the greatest frequence in regions near the equator. The term " albino" was first
applied by Portuguese sailors to the white negroes seen upon the coast of Africa, and it is
claimed that absence of pigment is not very uncommon among this race upon their own con-
tinent.
An albino of the Caucasian race has a milk-white but otherwise normal skin, a growth
of white, fine silky hair upon the head, and an absence of pigment in the choroid coat of the
eye, which gives the iris and pupil a red appearance, such as is often noted in a white rabbit.
In other respects the physical condition of an albino is normal, and the assertion that men-
tal weakness is associated with the general loss of pigment fails to be verified in a large
proportion of cases.
Partial albinism is frequently seen in this country among the southern negroes, and
some present the appearance of a piebald circus-horse. The white spot or spots remain
through life without change of size or tint. The affection is rarely if ever met with in the
white race.
(140)
a:
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D
LEUCODERMA.
LEUOODERMA.
Synonym — Vitiligo.
Leucoderma is an acquired loss of pigment, occurring in spots or patches on various por-
tions of the body. It is a rare affection, occurring generally in the middle period of life,
and often in persons who are seemingly in good health. The spots of leucoderma, unlike the
white piebald skin of partial albinismus, tend to a gradual increase in size, although in many
cases they remain stationary for years, and sometimes there is noted a spontaneous return of
pigmentation. The spots are always round at the beginning, become oval as they increase in
size, until, coalescing, they form large and irregular patches, of a milk-white color, or slightly
roseate hue where there is an active circulation of blood iu the part. The skin adjacent
to the leucodermatous patch is usually somewhat darker than noi-mal, thereby renderino- the
affection more striking in appearance by contrast. This increased pigmentation is most
marked in a narrow zone, just beyond the advancing edge of the white patch, which it sharply
defines. It shades gradually off as it recedes from the patch, and at the distance of an inch
or less the skin presents its normal hue.
The affection consists in an abnormal distribution of pigment, that which is taken from
the affected patch being apparently deposited in the immediate vicinity. At the outset there
are usually a number of smaU isolated spots, which naturaUy become fewer as they increase
in size and coalesce. The favorite starting-point of leucoderma seems to be the face, neck
and hands. From these parts the affection may spread indefinitely, and eventually affect
the greater portion of the body. Hebra mentions a case of long standing, in which the
white patches had coalesced and covered nearly the whole body, the normal pigment remain-
ing only in smaU broken patches upon the backs of the hands and feet, the elbows and the
face. Dr. T. F. Wood reports an interesting case in a colored woman. She was originally
quite black and of pure negro parentage. The white spots first appeared on the backs of the
hands and next upon the body, presenting an almost exact symmetry. The original color of
the skin gradually disappeared, and after twenty-six years the entire body was free from pio-.
raent except the nipples, and there remained a few black patches on the face. Wood reports
another case in which the pigment was in great measure restored after leucoderma had existed
a few years.
Since the affection is simply due to an absence of pigment in the cells of the rete, it fol-
lows that the patch is neither elevated nor sunken, neither thicker nor thinner, neither harder
nor softer than the normal skin. In some cases the leucodermatous patches appear to be
unusually susceptible to the action of the sun and other external irritants. There is never
any desquamation, and to the touch alone, this, unlike the majority of skin affections, im-
parts no information. The patient suffers no inconvenience, or at least experiences none of
the subjective sensations of cutaneous disease, such as pain, hypersethesia, anaesthesia or
(141)
DISEASES OF THE SKIN— ATROPHIC.
praritas, and the affection has no influence upon Ms general condition. When hairs exist upon
the patches theii' growth is unimpaired, although they are usually lighter in color, if not quite
devoid of pigment. The affection sometimes affects the scalp.
It is sometimes difficult, in glancing at a case of leucoderma, when the loss of pigment is
extensive, to say at once which is the normal skin — the dark or the light patches. A fact to
bear in mind is this. The advancing margin of a leucodermatous patch is always rounded or
convex, and the edge of the normal skin is of necessity concave. Accordingly, if in a given
case where doubt at first glance might exist, it is noticed that the whiter skin has a convex
or scoUoped margin, it is evident that we have either a patch of leucoderma or partial albi-
nismus, i. e., an affection characterized by loss of pigment ; while, on the other hand, should
the whiter portions of skin be found to have a concave border, or to be indented, as it were,
by the dark patches, it is evident in that case, that the white parts are the normal skin, and
that we have a case of chloasma or pigmentary naevus to deal with ; in other words, an
affection characterized not by loss, but by increase of pigment. At the outset the round
spots of leucoderma can be readily recognized as such, but when the skin is affected to such
a degree that neither the normal nor the affected skin is greatly in excess of the other, the
diagnosis may be difficult. It is simplified, however, when we bear in mind the peculiarity
of the development of the affection, viz. : its always presenting a convex or scoUoped mar-
gin. From partial albinismus, which in the negro race it very much resembles, it can be
distinguished by the fact of its not being congenital, but developing in adult life, and from
the additional feature of its not being stationary, but usually tending to indefinite extension.
In leprosy, cii'cular white patches are met vdih which resemble leucoderma. They do not
result simply from absence of pigment, however, and can be distinguished by the atrophic
changes and loss of sensibility.
Treatment. Of the treatment of leucoderma not much that is enco~iraging can be said.
By some it is pronounced iacurable, and there is difference of opinion among \vi-iters as to
the spontaneous return of pigment to leucodermatous patches. Arsenic, iron, phosphorus,
cod-Uver oU, and other remedies likely to exert an influence upon the nutrition of the skin
may be tried, with the conviction that they will act as well, if not better, than anything else
that might be given internally. Locally, an attempt may be made to lessen the pigmenta-
tion surrounding the light patches by painting the dark border with strong acetic acid, or a
one per cent, solution of corrosive sublimate, or by blistering it lightly. This will not tend
to cure the actual disease, but may lessen the unpleasant contrast existing between the white
patch and the surrounding skin, and thus render the affection less striking in appearance.
The same result might possibly be attained by applying mustard or other irritants to the
white patches, in the faint hope of inducing inflammation, and a subsequent pigmentation,
such aa is so often seen after eczema and other chronic skin affections.
(142)
ALOPECIA.
CANITIES.
Canities is a term applied to a loss of color of tlie hair, and is the capillary analogue of
leucoderma. The greyness or whitening of the hair may be congenital as in all cases of albi-
nismus where it is associated with absence of pigment elsewhere, or it may occur gradually,
as it is very apt to in old age. In these cases the canities is general, or at least tends to
become so. There are many cases, however, in which the loss of pigment of the hair is par-
tial and limited to one or more circumscribed patches. This may be congenital or develop
in youth or middle age. A patch upon the head is usually circular and shows little or no
disposition to increase in size. In some cases a portion of the eyebrow, moustache or beard
is affected, and as the loss of pigment is frequently unilateral, a singular contrast of the two
sides of the face may be presented.
A hair dye is the only remedy for canities, and it is a question in most cases whether the
remedy is not worse than the disease.
ALOPECIA.
Alopecia or loss of hair may be complete or partial. In rare instances infants are borL.
without hair and remain in this condition throughout life. It is possible, however, for com-
plete congenital alopecia to give place to a growth of hair as the child grows older. "With
this failure of hair-growth there is almost invariably a defective development of the teeth.
Partial alopecia is far more common than the complete form and is usually acquired. It is a
very frequent accompaniment of old age (alopecia senilis) and occtirs both as a general thin-
ning of the hair of the head and as a bald patch or tonsure on the vertex which often extends
forward over the crown. The loss of hair takes place gradually, without any notable change
in the condition of the scalp and is irremediable.
In young persons loss of hair (alopecia prematura) occurs from various causes. Fevers
and prolonged and severe illness of any kind are very apt to be followed by a temporary
alopecia, which usually disappears in a short time after the restoration of health.
Syphilis is extremely apt to occasion a thinning of the hair in the early stage of the dis-
ease, and when a secondary eruption has involved the scalp as well as the body, the baldness
is frequently of a peculiar patchy character. The hair loses its lustre and grows thin in spots
which give the scalp the appearance of having been partially plucked. This form of alopecia
affects the whole scalp and often the eyebrows and lashes. Absolute baldness is rarely seen,
and there is usually a tendency to a spotaneous restoration of the hair.
In late syphilis alopecia is extremely rare except as it is directly produced by a tuber
cular or ulcerative lesion of the scalp. Many writers on syphilis give a perfect descriptioi i
of aloi)ecia areata as occurring in the late stages of syphilis. This affection may undoubted! j
(143)
DISEASES OF THE SKJX—A moPUlC.
occur in syphilitic subjects, but its dependence upon syphilis is not at all probable in any
ca^^o
Premature alopecia is commonly associated with some abnormal condition of the scalp.
It i'j frequently observed to occur after seborrhcEa or pityriasis has existed for several years,
but in some cases the hair grows steadily finer and thinner without there being any tendency
to dandruff. This appears to support the view that the alopecia results from a failure in the
process of cornification and not, as many believe, from the accumulation of epidermis in the
hair follicles and a consequent atrophy of the hair.
In many cases of premature alopecia, and especially when the affection is inherited from
father and grandfather, it will be found that the scalp is drawn so tightly over the crown of
the head that atrophy of the hair bulbs must inevitably result. To a certain extent this
accounts for the usual development of alopecia upon the top of the head. Ordinary bald-
ness never occurs upon the temporal or occipital region where there is a muscular cushion
beneath the scalp, but on the other hand, it occurs only when the hair bulbs rest upon a hard
bed, sueh as the aponeurosis of the occipito-frontal muscle. This also accounts for the
absence of baldness among women, who are naturally endowed with a more plentiful supply
of adipose tissue beneath the skin, and which in case of the scalp, serves as a soft cushion or
bed for the hair bulb and thus exempts them from atrophy. The singular predisposition of
men to baldness has been attributed to the constant wearing of stiff hats and the consequent
interference with the blood supply of the scalp. But, taken in connection with observed
facts, neither this nor any other explanation thus far given will satisfactorily account for
the thinning of the hair upon the vertex which so frequently makes its appearance about
the age of thirty or forty.
Treatment. For the falling of the hair that so frequently occurs after fevers an ex-
pectant plan of treatment will usually suffice. The patient, however, is often anxious to do
something, and in addition to a general roborant treatment, the following lotion may be pre-
scribed as a capUlary stimulant :
51 Tincture of Cantharidia, • - - 10 parts.
Glycerine, 2 "
Cologne Water to - - - - 100 "
M.
The practice of shaving the head, recommended by so many hair dressers, and particu-
larly those who deal in wigs, is seldom if ever of any value. After shaving the scalp the
growth of the hair is far more noticeable and hence gratifying to the patient, but as the new
hair, after convalescence from fever, will come in just as readily without resorting to this
extreme measure, there is no occasion for the use of the razor. In some cases, moreover, the
hair of young women will never grow so long as before, if the razor is used.
The alopecia of early syphilis always tends towards a spontaneous cure, but the return of
the hair may be hastened by the daily inunction of the oleate of mercury of five per cent,
strength. This wiU also have a beneficial effect upon the papulo-pustular lesions which ai-e
(144)
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O
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ALOPECIA AREATA.
frequently scattered over the scalp when the eruption is copious iipon the body. Baldness,
resulting from tubercular or ulcerative lesions of the scalp, is apt to be permanent, as the hair
bulbs are usually destroyed.
When alopecia is associated with dandruff or any inflammatory condition of the scalp,
much benefit may be expected from judicious treatment. The falling of the hair can be
arrested even if the lost hair cannot be restored. The treatment of the diseased scalp ha?
already been mentioned in connection with seborrhoea, pityriasis and eczema capitis, but fre-
quently a falling of the hair is observed where there is no dandruff. In such cases a great
deal can be done by improving the patient's general health, and stimulating the scalp to a
healthier action. Anxiety, severe mental excitement, late hours and dissipation of various
kinds is a prolific source of alopecia, and if the patient's nervous energy is constantly exhausted
through such causes the nutrition of the hair becomes inevitably impaired and the resulting
baldness is beyond the reach of any "tonic " or " restorative." When, as is frequently the
case, the hair is abnormally dry and the scalp white and pasty in appearance, the daily
inunction of a very little oil, with frequent shampooing, will produce a speedy and beneficial
effect.
ALOPECIA AREATA.
Synonym — Porrigo Decalvani.
Alopecia areata is a form of baldness which begins suddenly at one or more points and
rapidly produces smooth, white patches of circular shape and variable size. These tend to
increase peripherally to a greater or less extent, and often run together in such a manner as
to form large irregular patches, or long streaks of baldness. The disease not only attacks
the scalp and beard, but also the pubes and axillae, and in rare instances not a single hair
remains upon any portion of the body. It has no relation whatever to ordinary baldness
occurs very frequently in young persons, and may attack those who have naturally a luxuri-
ant growth of hair. It is unaccompanied by itching or other subjective sensations. After a
variable length of time a new growth of fine downy hair appears upon the bald spots. This
new gro^vth is frequently white at first, but gradually becomes pigmented, and in time no
trace of the affection is to be seen. When the bald spots are numerous some will be found
to recover far more quickly than others, and in some cases, when the hair is apparently
growing normally once more, a relapse may suddenly occur.
Concerning the etiology of the disease, very little can be positively asserted. It appears
to be dependent upon a trophoneurosis or functional nerve derangement. A parasitic origin
has been claimed for it, but the claim is by no means established. Two or more cases fre-
quently occur in a family, and seem to indicate an hereditary tendency or predisposition.
Diagnosis. The diagnosis of the affection is easy. Trichophytosis of the scalp may
bear a resemblance, but in the latter affection the hairs break off instead of falling out, and
leave rough, scaly patches, quite different from the smooth, velvety areas of the former.
The two affections, however, may co-exist in some cases.
(145)
DISEASES OF THE SKIN— ATROF RIO.
Treatment. The treatment of alopecia areata is, to a certain extent, empirical, and the
results obtained are exceedingly variable. In some cases there is a tendency to spontaneous
recovery, and hair may grow again upon the bald spots in the course of a few months, even
without treatment. Indeed, nearly every case wiU get well in time, but it often requires a
lonf time, one or two years, perhaps, and though, in many cases which recover spontane-
ously, the credit is unjustly awarded to the remedies employed, it is, nevertheless, certain
that judicious treatment tends to hasten a cure. In every case a guarded prognosis should
be given as to the time required to effect a cure, Othervdse the result may bring discredit
to the physician and disappointment to the patient.
As nervous debility, headaches, and other ills, often precede and accompany the affec-
tion, it is important that these be detected and appropriately treated. If the general condi-
tion of the patient is not what it ought to be, attention should be directed to this point
rather than to the baldness. There is no special internal remedy which can be recommended
above others, although on theoretical grounds the various nervine tonics would seem to be
indicated. The local treatment consists in epilation of the loose hairs surrounding the bald
patch ; in occasional blistering of the denuded scalp ; in frequent shaving of the new gro-n1;h
of hair, and in the persistent use of various strongly stimulating remedies. Blistering and
shaving are remedies highly esteemed by some, but it is a question whether they are as bene-
ficial as they are disagreeable. I have usually dispensed with them, and relied mainly on
the use of local stimulants, of which a strong solution of ammonia is one of the most effi-
cient. If the odor of the ammonia is objectionable, a lotion of equal parts of the tincture
of cantharidis and bay-rum may be applied morning and night. A host of other stimulat-
ing remedies have been recommended, but they all act in the same way. There is no benefit
to be derived from changing from one to another, except as it may amuse the patient or curb
his impatient desire for a speedy cure.
The following applications have been recommended in this affection :
9
M.
9
M.
M.
Castor Oil, - - - - 15 parts.
Carbolic Acid, - - - 3 "
Tincture of Cantharrides, - 15 "
Oil of Rosemary, - - 2 "
Alcohol to ... 100 "
Oil of Lemon, - - - - 2 parts.
Oil of Sweet Almonds, - 12 "
Stronger solution of Ammonia, 12 "
Spirit of Rosemary to - 100 "
Yellow Sulphate of Mercury, 3 parts.
Fluid Extract of Nux Vomica, 10 "
Simple Ointment, to - 100 "
5^
M.
M.
Oil of Turpentine, - . 15 prats.
Castor Oil, - - - • 16 "
Tincture of Origanum, - 4 "
Camphorated Oil, - - 30 "
Volatile Liniment to - 100 "
Liniment of Aconite, - - 25 parts.
Liniment of Ammonia, • 25 "
Liniment of Camphor, - 25 "
Liniment of Chloroform, - 25 "
Salicylate of Sodium, - 10 parts.
Carbolic Acid, - - - 6 "
Petrolatum to • - - 100 "
M.
(146)
ATEOPHlA. CUTIS.
ATROPHIA PILORUM.
As a result of various wasting diseases, such as phthisis, and as the direct effect of cer-
tain affections of the scalp, such as seborrhoea and ringworm, the hair often becomes dry,
thin and brittle. The growth is checked and the ends of the hair usually split into several
filaments. In rare cases a somewhat similar defect of nutrition is idiopathic. The shaft is
apt to be flattened, and in a case reported by Duhring, there was fissure of the bulb or por-
tion of the shaft within the f oUicle.
TRICHOREXIS NODOSA-
A peculiar condition of certaia hairs of the beard and moustache has been described by
various writers under the name of trichorexis nodosa. As the term implies, the affection is
characterized by the appearance of minute nodules or swellings scattered along the shaft of
the hair, at which poiuts fracture is very apt to occur. This leaves a brush-like condition of
the free extremity of the hair. The affection is a rare one, and Little cau be said respecting
its etiology and treatment. It does not appear to be parasitic in character, and persistent
shaving is the only known remedy.
In a case reported by Smith of Dublin, the nodules were pigmented, and the fracture of
the hair occurred in the shaft between the nodules.
ATROPHIA CUTIS.
There are two forms of atrophy to which the skin is subject. There is a diffused atrophy
or thinning of the skin (atrophia cutis propria), and a localized atrophy which appears in the
form of lines (strise atrophicse), or roundish spots (maculae atrophicae). The first form may
be the result of age (atrophia senilis), in which case it is general and associated with wasting
of the muscles. The skin, and notably the corium, may become thinner than normal, the
epidermis dry and wrinkled, or a process of degeneration may take place, in which case there
is more or less structural alteration, an increase of fatty matter and pigment being found.
Diffused atrophy may assume the condition which has been described under the head of
"glossy skin." This usually attacks the fingers, the skin of which becomes, smooth red and
shiny. The hairs are shed, the nails become affected and painful excoriations and ulcers
form. The affection is a painful one and is generally the result of some lesion of the nerve
trunk.
The localized form of atrophy produces whitish streaks or discs which present a finely
wrinkled and cicatricial appearance. Upon the abdomen of women who have borne children
these atrophic lines are not uncommon and result from the over-distension of the fibrous
portion of the skin. They are Ukewise frequently observed upon the bi easts of those who
(U7)
DISEASES OF TEE SKIN.— ATROPHIC.
have nursed cMldren, but pregnancy and lactation cannot always be cited as a cause of these
strijE, for I have observed them upon the breast, abdomen and thighs of young girls as well
as in men. Pre-existent obesity may sometimes account for their appearance in the male sex,
but often the lesions appear to be idiopathic in their origia. When seen at an early stage
the lines are often of a pinkish hue and elevated above the level of the skin, the white and
cicatricial appearance being a later development. In this regard the affection bears a sti-ong
resemblance to morphoea. Indeed there appears to be an intimate pathological relation be-
tween the two affections, and Duhring states that in several cases he has seen well-marked
atrophic lines and spots associated with the more characteristic patches of morphoea.
The affection gives rise to no inconvenience and is not amenable to treatment.
ONYCHATROPHIA.
In certain affections involving the greater portion of the skin (notably lichen ruber) a
thin and brittle condition of the nails is frequently observed. The same condition often
appears without apparent cause and is sometimes hereditary. The surface of the nail loses
its lustre, numerous ridges or splits running parallel with its long axis appear, and the free
margin and side of the naU become broken and uneven. In some cases numerous dents or
pits are seen scattered over the surface.
Treatmejtt. When the defective nutrition of the nail arises from a chronic inflamma-
tory condition of the matrix, whether the nail substance be increased or lessened in amount,
I have seen a good result foUow the repeated immersion of the end of the finger in the fol-
lowing pigment.
9. Chrysarobio, 10 parts.
Salicylic Acid, - - • - 10 "
Ether, 10 "
Collodion to 100 "
M.
(U8)
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O
CHAPTER VI.
NEOPLASTIC DISEASES.
CICATRIX.
Synonym — Scar.
A cicatrix is a new growth of connective tissue wliich takes the place of a loss of sub-
stance of the corium A loss of epidermis is replaced by a normal cell growth, but when a
portion of the corium or true skin is destroyed by injury or disease, the formation of a scar is
inevitable. The margin of a cicatrix is well defined, and its surface is either continuous with
the level of the surrounding skin or raised or sunken. Its form is varied, being punctate,
linear, discoid or reticular, according to the nature of the preceding ulceration. It is less
pliable than the healthy skin and is devoid of hair and glands. Its color is at first light red,
but after a lajjse of time which varies in different individuals it becomes colorless or remains
more or less pigmented. It may be movable over the underlying tissue, or bound down to
the fascia or periosteum beneath.
The skin diseases which are superficial in their character, such as eczema, psoriasis and
pemphigus, do not as a rule leave scars, although these may occasionally be produced by
severe friction of the clothing, vigorous scratching, or by any cause sufficient to injui-e the
corium. In certain vesicular or pustular affections which are more deeply seated, such as
zoster, acne and fiiruncle, scars are frequently left, whUe in lupus, leprosy and ulcerative
syphilis they invariably result from the loss of cutaneous substance,
A cicatrix is composed of dense fibrous tissue, containing vessels, and is covered by a
thin layer of epidermis. A tendency to contraction is usually a marked feature of the
growth, and when the loss of substance has been considerable and has involved a lax, movable
tissue, more or less deformity is apt to be produced by the cicatricial formation. In some
cases the motion of a joint is seriously impaired, the eyelids are everted, or the head drawn
to one side, while in others an artificial web is formed between the fingers or between the ear
and scalp.
Cicatricial tissue may be the seat of eruptions which affect the surrounding skin, e. g.,
psoriasis, and is especially liable to become the seat of keloid. Neuralgic pain in scars some-
times results from the imprisonment of terminal nerve fibres in the dense tissue.
Treatment, The character of a cicatrix depends largely upon the treatment of the
wound or ulcer which precedes it, and judicious surgical measures Avill often cause a smooth
scar to form in place of the puckered or lumpy condition which would naturally re-
(149)
DISEASES OF THE SKlIf.— NEOPLASTIC
siUt. Much care should always be exercised in the coaptation of cut or torn portions of
skin, and the prominent masses which are sometimes seen in large ulcers should be leveled by
the use of nitrate of silver or the actual cautery before complete cicatrization ensues. A scar
once formed can never be entirely removed, but a plastic operation will often improve its
appearance and lessen its objectionable features.
The deformity resulting from the contraction of a large ulcerated surface, which is espe-
cially apt to disfigure the face or impair the motion of joints, can be remedied to a certain
extent by the operation known as skin-grafting.
KELOID.
Keloid is a cutaneous tumor which usually develops upon the site of a cicatrix. It results
from a new growth of connective tissue, and may affect various portions of the body. It is
variable in size, and thongh usually small, it may in rare cases assume immense proportions.
It is generally a single growth, but may occur in the form of multiple tumors, especially when
it arises from cicatrices. Its shape is usually oval or irregular, and more or less flattened, and
one or more straight or bifurcated processes are seen projecting in every typical case. These
have given origin to the name keloid (like the claw of a crab). In some instances the growth
rises abruptly from the surrounding healthy skin and forms a plump convex tumor, while
in other cases it is reticulated in appearance, from the interlacing of cicatricial ridges. The
margins of the growth are sometimes elevated and inclose a central depressed area. Its sur-
face is smooth, of a whitish or duU pinkish hue, and is frequently streaked with a fine net-
work of small dilated vessels. The grovrth is firm and elastic to the touch, usually tender
when pressed upon or squeezed, and in some instances gives rise to severe intermittent
pain even when carefully p'-otected. The processes radiating from the gro^vth tend to
contract and produce a puckered condition, such as surrounds the cicatrix of an extensive
burn. A favorable site of keloid is the sternal region, where it appears as an elongated flat-
tened tumor crossing the median line in a transverse direction. It occurs frequently upon
the back and sides and also upon the scalp and face. It is slow in its development, and is
never associated with any constitutional symptoms. It neither ulcerates nor tends as a rule
to spontaneous disappearance, but after reaching a certain size remains in the same condition
for many years.
One of the most remarkable cases of keloid which I have seen was in the Philadelphia
Hospital, under the care of Dr. Maury, who gave the following history of the case, together
with an illustration in the Photographic Review (Oct. 1878). The patient, a colored man,
(formerly a slave), aged twenty-eight years, was above the ordinary height, of large frame
and very muscular. His family history revealed nothing from which to trace the cause of
his disease. Wlien eight years of age, a small abscess made its appearance on the anterior
part of the neck, which, on being opened, discharged an ounce of pus. As the result of tlus
abscess, a well-marked induration followed at the original seat, which gradually extended in
(150)
KELOID.
both directions around the neck. After nine years' growth it had half encircled the neclc,
and was about two inches in width. At this time the growth was removed. The wound
healed kindly in six weeks, but the line of the cicatrix was speedily occupied by a hard
rounded ridge, which slowly extended and enlarged.
Eighteen months later an accidental wound was inflicted by an axe on the posterior part
of the neck. This wound also presented a hard, nodulated cicatrix, which crept around the
neck to join the one in front. Seven years after the first operation it was removed again, at
which time it had extended around the entire neck. Three months were occupied in the
healing of the wound, which also assumed the same morbid action. At date of report there
were thirty-seven tumors of variable size, one resembling, in a marked degree, the ruffles
worn in the time of Queen Elizabeth. The two original growths were thoroughly blended
and formed one solid mass, touching at the posterior part of the neck. It measui-ed twenty-
eight inches in its greatest circumference and five inches in its perpendicular diameter. It
was plicated and had deep fissures separating the folds, from the bottom of which exuded
a thin, yellowish, offensive fluid. It was not painful, normally sensitive, and the entire mass
could be moved \\'ithout difficulty, thereby indicating only a cutaneous attachment.
The cause of keloid is unknown. Observation teaches that in the vast majority of cases
it develops at some point where cutaneous injury has taken place. The cicatrices of acne
upon the back, of boils or carbuncles upon the nape of the neck, of variola upon the face,
and of vaccination upon the ann are frequently observed to be the site of keloidal growths.
The removal of lupus by scraping has been followed in many cases by keloidal cicatrices,
especially in strumous subjects. Purdon reports a case of keloid following psoriasis, and
Taylor a case in which numerous keloidal growths developed upon the site of syphilitic ulcers,
and occasioned ten-ible itching at night. Negroes appear to be more frequently affected by
keloid than white persons. Whether this is due to a peculiarity of the race or to the fact
that their skins are more frequently pitted with variola, scarred by strumous abscesses, and
disfigured by the lash, may be a question. The disease is never hereditary. A division of
keloid has been made into a spontaneous and a cicatricial variety, the former embracing
those cases of idiopathic origin, the latter comprising those which develop upon cicatrices.
As it is well known that keloidal tumors of considerable size and attended by pain result
from the most trifling injury to the skin, it seems quite probable that every case of keloid is
of traumatic origin, and the so-called idiopathic cases have been produced by the prick of a
pin or some other insignificant injury of which the patient took little or no notice at the time.
The term spurious keloid might be advantageously abandoned or applied to a form of hyper-
trophic development of cicatricial tissue sometimes met with, and which differs from true
keloid.
The name keloid, like many other dermatological terms, has been diverted from its ori-
ginal signification and applied to distinct affections. We hear accordingly of Alibert's keloid
and Addison's keloid. Concerning the nature of the latter affection, or morphcea, there is
much doubt existing among dermatologists, but one thing is certain, it is not keloid.
(161)
DISEASES OF THE SKIN— NEOPLASTIC.
Diagnosis. The diagnosis of the disease is usually an easy matter. The firm, elastic
tumor, the processes (which however are not invariably present), the puckering of the sur-
roundiao- skin, the long duration of the growth and the unimpaired health of the patient are
characteristic features which will serve to distinguish it from other affections. The diagnosis
of genuine from spurious keloid depends, according to -writers who make the distinction,
upon the idiopathic or traumatic origin. The origin, as has been remarked, is often uncer-
tain and the distinction is unnecessary. It must be remembered, however, that cicatrices
often become thickened and lumpy through condensation of tissue and are with difficulty
distinguished from keloid.
Treatment. In the treatment of the disease success seems to depend in great measui-e
upon idiosyncracy on the part of the patient. A method which will succeed admirably in
one case will fail utterly in another, and caution must be observed in stating beforehand
what the resiilt of treatment will be. Excision of the tumor or destruction by caustics
usually does more harm than good, as the growth usually reappears even before the wound
is healed, and soon reaches a greater size than before the operation. This is especially the
case when the growth is progressive. When there has been no increase in size for several
years, caustic potash or glacial acetic acid may be cautiously used. I have seen a case of
reticulated keloid following variola, which was greatly improved by parallel incisions and the
use of concentrated acid. Vidal reports two cases in which scarification alone was productive
of benefit. In one case he adopted this treatment with a view to relieve the patient of pain.
The scarifications were numerous and made at right angles to each other. After three such
operations he was satisfied that a real amelioration had taken place, and by a continuation of
the treatment succeeded in nearly curing the disease. An ointment of iodide of lead or of
iodide of potassium or elastic collodion may be applied with a certainty of at least doing no
harm. Where excessive pain is present hypodermic injections of morphia or anodyne lotions
are required.
For the treatment of keloidal acne or the hypertrophied cicatrices which often follow
the incision or spontaneous evacuation of small, indolent abscesses in the cheek, Bazin
recommended frictions every second day with the oil of cade, and night and morning a tea-
apoonf ul of the following in barley water :
51 Iodine, 1 part.
Iodide of Potassirmi, - - - 10 parts.
Tincture of Conium, ... 100 "
Water to 1000 "
FIBROMA.
Synonyms — Molluscum Fibrosum. Fibroma Mbllttacum.
Fibroma is a new growth of connective tissue which may be found in various organs of the
b >dy. Occurring in the skin it forms one or more tumors which often vary greatly in size
(152)
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FIBROMA.
aud appearance. These involve tlie corium and reticulated subjacent tissue. In all cases
they are painless and benignant in character.
The most common and simplest form of fibroma is apt to occur upon the face in adult
life in the form of a pea-sized hemispherical nodule of firm consistence. This is most fre-
quently seen upon the side of the nose or cheek and is often spoken of as a "wart" or
"mole." Occasionally it is the seat of a growth of coarse and stiff hairs (nsevus pilosus).
Another simple form of cutaneous fibroma occurs as a small pouch-like tumor or polypus
of the skin which may be flattened or elongated and connected by a pedicle. This gro^vth
is usually seen upon the neck, breast or back, and is apt to be more or less pigmented. The
sebaceous ducts are sometimes distended and white, cheesy threads can be extruded by pres-
sure. Very small, thread-like appendages are sometimes observed upon the neck of females
with a coarse skin, and have been described under the name of Acrochordon.
In a case of multiple fibroma numerous soft and flaccid tumors are scattered over the sur
face of the body. These vary in size from a pea to a walnut, and produce an affection of
striking appearance, although exerting no influence upon the health and general condition
of the patient. They are sometimes congenital, increasing gradually in size up to a certain
limit, but are generally an acquired growth. In many instances the affection appears to be
hereditary and affects two or more members of a family. Some of the tumors may be of a
somewhat firm consistence and feel like a split pea imbedded in the skin, but the majority
are pouch-like, and pressure with the finger shows that the corium at their base is thinner
than elsewhere. In color they differ very little from the surrounding skin.
Occasionally a fibroma becomes large, pendulous and pedunculated. It may occur alone
or in connection -ivith the smaller growths already described. The surface of this pyriform
tumor may be smooth and white, the skin appearing normal in structure, though stretched
by the increased growth of fibrous and areolar tissue beneath. In some cases the sebaceous
glands upon the surface are enlarged and the ducts unusually prominent. Its color is usiially
pale, although the most dependent portion may present a dull red hue, and in some cases
become the seat of ulceration. The constricted base is usually of a denser structure and the
pedicle is often connected with the deep reticulated layer of the skin.
In certain rare cases the fibrous growth hangs in one or more folds of skin from a broad
base and constitutes the affection which has been termed Pachydermatocele or Dermatolysis.
This growth differs in no essential respect from the pedunculated tumor, although the corium
is apt to be specially involved. It may coexist mth a number of small sessile fibromata and
is identical in nature, though differing in shape and appearnce. The skin in some cases
appears coarse in texture and is slightly pigmented, while in others it is atrophied from ten-
sion and appears smooth and fine. The periphery of the growth is generally more dense than
the included, projecting portion.
The cause of this affection is unknown. It occurs in both sexes and in individuals whose
general condition is good. A stunted condition of both mind and body has been noted, how-
ever, in certain cases.
(163)
DISEASES OF THE SKIN.— NEOPLASTIC.
Diagnosis. Small fibromata of firm consistence might be mistaken for sarcomata, but
in the latter case the tumors are of a dull red hue and tend to ulcerate. Mollusca are readily-
distinguished by their central aperture from which curd-lilie contents may be expressed.
Tr"EATMEnt. The treatment of fibroma is not imperative, as the affection usually occa-
sions no discomfort. In a few cases spontaneous involution of certain tumors has been
observed. When the growths are small they may be let alone, when large and pedunculated
they may be removed by the knife, galvano-caustic loop, or elastic ligature. In the pendu-
lous and especially the plicated form, the liability to erysipelas must be considered before
attempting an operation, but such growths have been successfully removed by Mott, Danzel,
Bryk, Pollock and others.
XANTHOMA.
Synonyms — Xan thelasma. — Vitiligoidea,
Xanthoma is an affection in which one or more circumscribed patches or small tumors of
a yellowish color gradually develop in the skin. The lesions are of a chronic character, and
are most frequently observed upon the upper eyelid, near the internal canthus. In this
locality xanthoma usually appears as an oval patch which is but slightly, if at all, elevated,
and presents the appearance of being imbedded in the skin. As it frequently occurs in wo-
men with a dark complexion and dark pigmentation around the eyes, its yellowish hue con-
trasts strongly with the adjoining skin. One or both lids may be affected, and with the
exception of the disfigurement, they occasion no discomfort to the patient. Upon other
poi-tions of the body xanthoma is apt to assume a tubercular form, and in some cases small,
rounded tumors develop. Upon the palms and soles, and on the flexor surface of the joints
the growth usually invades the natural creases of the skin and produces a number of yellow-
ish or whitish lines or streaks. These varieties of the disease may be designated as xantlionia
planum, xanthoma tuberosum, and xanthoma striatum.
The cause of the affection is often obscure, but most of those who have carefully studied
a number of cases are disposed to connect it with hepatic disease. In a few cases, in which
the cutaneous lesions appeared suddenly and gradually disappeared, diabetes was present
Diagnosis. The affection is readily recognized when it occurs upon the eyelids, and in
a weU-developed form. The only affection which at aU resembles it is milium. In the for-
mer case the lesions are flat and evince a tendency to coalesce. In the latter the lesions are
isolated, elevated and easily removed from the skin after a slight incision.
Treatment. The best plan of treating xanthoma palpebrarum is excision. I have
partly destroyed the growth and rendered it comparatively inconspicuous by the use of f,he
electrolytic needle, and would recommend this plan of treatment in cases where the patient
objects strongly to the use of the knife. Xanthomatoua tubercles upon the body may be
excised or left untreated.
(154)
TELANGIECTASIS.
NEUROMA.
Neuroma of the skin is a rare affection in wMch one or more nodules develop and become
extremely painful. The few cases reported have occurred in men, and the seat of the affec-
tion has been in the region of the brachial or sacral plexuses of nerves. In a case reported
by Duhring the tubercles, which were numerous upon the shoulder and arm, were of a pur-
plish color and slightly scaly. The pain, which was absent at first, became excruciating
after a few years, and occurred in paroxysms of about an hour's duration. Exsection of an
inch of the brachial plexus of nerves was followed by a marked diminution of pain, and a
decrease in the size of the nodules.
TELANGIECTASIS.
Telangiectasis is a dilatation of one or more fine superficial blood vessels, and is usually
observed upon the face. It is never a congenital affection, and usually develops in youth or
middle age. It may exist alone or in connection with other affections of the skin. In rosa-
cea it is generally a marked feature of the disease and is seen chiefly upon the wings of the
nose. In erythematous lupus and morphoea the margin of the patches often presents a fine
network of enlarged capillaries, while in moUuscum and superficial epithelioma the fine red
vessels may be seen running up over the abrupt edges of the growth.
In telangiectasis occurring alone the vascular dilatation may be localized or diffused.
In the former case it appears as a bright red point or blotch, usually upon the cheek, and is
often the result of some slight injury to the skin which may have been long forgotten by the
patient. Sometimes the dilated vessels form a minute and elevated tumor, while in other
cases thpre is no elevation whatever, and fine red lines radiate like the legs of a spider from
the central point or plexus of vessels (Nsevus araneus).
In the diffused form of telangiectasis a portion of skin will present at a distance a dull
red hue which, on close inspection, is found to result from an extensive arborization of fine
superficial vessels. This condition is often noted on the cheeks of coachmen and others
whose faces are constantly exposed to the cold air and wind.
Telangiectasis is never accompanied by any subjective sensation, such as pain or
itching. It usually develops slowly and remains for years without undergoing any notable
change. In some cases it may disappear spontaneously.
Diagnosis. A red point or patch produced by a dilatation of capillary vessels might be
mistaken for an inflammatory affection of the skin, but the absence of heat, pain and swell-
ing is an important diagnostic feature. Furthermore, the chronicity of the red spot and
the fine curving or tortuous Lines apparent on close examination will reveal the true nature of
the affection. Telangiectasis differs from wine-mark in not being congenital and never form-
ing an extensive and circumscribed patch.
(155)
DISEASES OF THE SKIN— NEOPLASTIC.
Treatjiext. For the destruction of the dilated vessels in telangiectasis several plans
have been employed with success. Transverse scarification, repeated if necessary, will usu-
ally effect their obliteration, although it is apt to leave faint linear cicatrices. When the
superficial cai)illai'ies upon the sides of the nose are elevated, as is frequently the case in
rosacea, the vessels may be laid open with a fine bistoury and the persulphate of iron in
solution or the nitrate of silver appUed to the fresh cut. In general, however, the dilated
vessels can best be destroyed by means of a fine needle attached to the negative pole of a
galvanic battery. This should be introduced, if possible, at the point where the vessel
emerges from the deeper layer of skin, although it is often necessary to introduce the needle
at several points along the course of the vessel. This operation is not pai'ticiilarly painful
and is always effective.
N-S:VUS VASCULOSUS.
Synonyms — Angioma Simplex. — Wiite-mark. — Fire-mark,
Nsevus vasculosus is an affection in which a dark red or purplish patch results from a
dilatation or new growth of cutaneous vessels. This is a condition of the skin similar to that
seen under normal circumstances upon the vermillion border of the lip. The affection is
always congenital or apparent shortly after birth, and in this respect it differs from telangi-
ectasis.
A vascular nsevus has usually a smooth surface, an irregular form and a rather sharply-
defined outline. In certain well-marked cases the smooth surface is broken here and there
by the development of smaU erectUe tumors of the size of a pin's head or a small pea. In
the very worst cases the livid patch may be the seat of numerous soft, rounded tumors of
variable size which give to the slcin a warty or molluscous appearance. These are not con-
genital, but develop gradually upon a comparatively smooth i^atch.
The extent of surface involved in vascular nsevus varies greatly in different cases. In
one case a faint pinkish mark no larger than a quarter dollar may be seen at the edge of
the hair upon the occiput or neck, a site where the mildest form of vascular njevus is
very common. In another case a red mark of a florid or livid hue may cover one-half or
the greater portion of the face and extend down upon the neck and trunk. In one case now
under my care a succession of patches of variable size extend from the forehead to the foot,
nearly one-half of the left side of the body being affected. The upper portion of the body
and the face in particular is unfortunately the favorite site of this affection. Although the
red patches may occur upon both sides of the face or body they never manifest any tendency
to symmetrical distribution. In the great majority of cases the affection is unilateral, but
when bilateral, one side is always affected to a much greater extent than the other.
The color of vascular naevus varies from the lighest shade of red to a dark purplish-blue
or slate color. The general tone of a patch or a number of patches in a given case does not
admit of great variation, although some portions of the affected skin may be slightly darker
(156)
N^VUS VASCULOSUS,
than others. In cold weather a vascular ngevns usually appears darker or bluer than at other
times, on account of the diminished flow of fresh arterial blood to the part. On the other
hand, active exercise or whatever tends to cause cutaneous congestion will temporarily in-
crease the bright redness of the patch.
Treatjient. Up to a recent date the profession and the laity have shared the opinion
that nothing could be done for the relief of patients aiBicted with a wine-mark. In most
works on surgery no plan of treatment is even suggested for this flat form of nsevus, and in
spite of the zealous endeavors of a few dermatologists to devise some successful means of
removing this common deformity of the skin, it must be confessed that no proposed plan of
treatment has as yet met with general favor. Some encouraging results have nevertheless
been attained, and it may be confidently asserted that all cases of wine-mark, and especially
the worst cases, can be improved by treatment.
To remove a wine- mark by deep cauterization is a simple matter, but the dead white
cicatrix which would result from such a procedure would generally be regarded as quite as
unsightly as the red patch. The object of every plan of treatment should be the destruction
of the blood-vessels with the minimum amount of injury to the skin.
A vascular nsevus of superfcial character and light color is best treated by mild cauteri-
zation of the patch, repeated at intervals until a beneficial effect is produced. This requires
time and patience on the part of both physician and patient. The application which is least
apt to injure the skin and still capable of lessening the redness in some degree is carbolic
acid. This may be applied pure to a portion of the patch and re-applied in a week or ten
days, when the outer layer of skin has peeled off and left a smooth surface. It is advisable
to apply the acid in the form of a broad stripe running across the patch in such a manner
that the effect of treatment may be noted by the subsequent contrast between the stripe and
the untreated portions of the nsevus. If the acid be applied to a considerable portion of skin
some susceptible patients wUl complain of dizziness or perhaps evince marked symptoms of
intoxication from absorption of the acid.
Should this comparatively mild and almost painless procedure fail to produce the desired
residt of removing the stain, the liquid ethylate of sodium may be rubbed into the skin by
means of a glass rod. This wiU destroy the epidermis and leave a raw surface which becomes
quickly covered with a thin blackish crust. A few repetitions of this application, which
causes considerably more pain than the carbolic acid, will destroy the redness in great part
and leave a cicatricial condition of the skin which is almost imperceptible.
In some cases I have dotted the surface of a nsevus with nitric acid, which has the effect
of lessening the red color, but is more apt to leave the skin rough or uneven when applied to
a large patch. Moreover, if this acid is carelessly handled and an ulcer forms in conse-
quence, the resulting cicatrix may become raised above the surface of the skin and present
an unsightly appearance.
Cauterization of the surface of the wine-mark by the means of a double-canvex lens or
"burning glass," has been highly recommended as a curative measure. Here again the pro-
ds?)
DISEASES OF TRE SKIN— E EOF LAST IC.
duction of ulceration must be carefully avoided. I have never tested tMs method of treat-
ment, but in one case thus treated, which I saw some years ago, the cheek was covered by
numerous keloidal elevations as the result of the solar operations. In one case ef extensive
njevus I have known the galvano-cautery to be cautiously used with the effect of partially
obliterating the vessels and leaving a smooth sui'face.
The treatment of wine-mark by linear scarification was proposed by Squire, of London,
a few years ago, and on account of the novelty of the method and the positive assertions as
to its great value, various dermatologists in Europe and America were led to test its merits.
The reports made by these were not at all favorable to the plan of treatment, and so far as I
am aware no one but the author of the operation has succeeded in removing a wine-mark by
scarification. In my hands it has failed to accomplish the desired result, but still I am not
prepared to condemn the operation as others have done, but deem it possible that the failure
in many cases reported has resulted from a lack of experience in the performance of the
operation, which necessarily requires great care and skill. Possibly the claims first made
for the operation were based upon an enthusiastic belief in its value rather than upon a de
liberate study of results in numerous cases.
The operation of linear scarification as proposed by Squire consists in first freezing a por.
tion of the affected skin by means of ether spray and then making parallel incisions with a
thin scalpel or an instrument composed of a dozen or more blades and called the "multiple
scarifier." The cuts should be no more than a sixteenth of an inch apart, and as long as
they can be made quickly and straight. The bleeding is slight if the cuts are not over a
sixteenth of an inch in depth, and can easily be arrested by applying a piece of blotting
paper and slight pressure. This piece of paper should be gently peeled off before it has
dried, and in the direction of the incisions. Squire says: "If the little operation be exe-
" outed cleverly, that is to say, if the skin is weU frozen, the instrument exquisitely sharp,
" the incisions made with perfect regularity of spacing and with uniform equality of depth,
"and a special care be taken to avoid any accidental dragging of the strips apart, so that no
"clot is formed in the incisions ; if such detaUs be well cared for, it wUl be found that the
" cuts Ileal with surprising rapidity and became within a few days quite invisible. The pro-
" cess of scarification must be many times repeated, at intervals of a few days, that is to say,
"as soon as the last cuts are healed. At each operation the direction of the parallels of the
" second operation should be oblique to those of the first operation, and so on. The process
" is a tedious one, but the result of it is highly satisfactory, for the stain is made to disap-
" pear without the production of a scar."
The tattooing of nsevus by needles immersed in carbolic acid has been recommended by
Sherwell, and I have seen patches lightened in color by this method of treatment. Owing
to the difficulty, however, of getting the acid in any amount beneath the surface of the skin
this plan will be found much less effective than the use of needles connected with a galvanic
battery.
The electroljiic treatment of wine-mark I have practiced during the last five years, and
(168)
ANGIOMA.
although I cannot claim that the operation accomplishes all that conld be desired, I hc^ve
repeatedly succeeded in transforming a dark and unsightly stain into a smooth patch of a
light pink hue. The object aimed at in the treatment of wine-mark by electrolysis, as in the
case of scarification and puncture, is to excite sufficient inflammation to destroy the fine net-
work of blood vessels. As the galvanic current is more active and at the same time more
manageable than acid adhering to the points of needles, it is not strange that this method
should produe the desired effect in the speediest manner and with the least injury to the sur-
face of the skin.
The operation is somewhat similar to that already described in the treatment of hyper-
trichosis (page 188). A single needle, or a number of needles combined in one instrument,
is attached to the negative cord of a constant current battery and inserted into the skin by
a quick pressure. The electrolytic action which ensues upon the completion of the circuit
serves to destroy to a certain extent the fine plexus ol superficial vessels which constitutes the
red mark.
ANG-IOMA.
The term Angioma is often used as a generic title, applicable to all new growths of blood
vessels and lymphatics. As the termination of the word indicates a tumor it would seem
more convenient to restrict its application to erectile tumors composed of blood vessels. To
this condition the distinctive name of Angioma cavernosum has been applied.
The angiomatous tumor is sometimes congenital but usually develops shortly after birth.
During childhood it may reach a sufiicient size to cause gi-eat deformity and annoyance. It
is composed of a net- work of trabeculse, the interspaces representing dilated blood vessels
and freely communicating with each other. The margin of the growth may be abrupt or
gradually shade off into healthy tissue. The tumor is soft and compressible, but the blood
returns as soon as the pressure ceases. The color of the tumor varies from a dull red to a dark
purple in accordance with the arterial or venous character of the contained blood.
Angioma may be single or multiple, although the former is usually the case. It is most
frequently observed upon the scalp and face. The lips, eyelids and lobe of the ear are
affected mth especial frequence. The course of the affection is variable. "WhUe in many
cases the growth remains stationary after having reached a certain age, in other cases it con-
tinues to enlarge and sometimes manifests a tendency to become inflamed and even gangre-
nous.
Treatment. The first step to be taken in the treatment of an angiomatous tumor occur-
ring in infancy is to watch it carefully untU a tendency to an increase in size becomes evi-
dent. In this case operative treatment is always advisable. If the growth is no larger than
a half cherry and the child has not been vaccinated, this operation may be performed ui)on
the surface of the tumor which is apt to be destroyed, wholly or in part, by the resulting
inflammation. If the tumor is so situated that constant pressure can be exerted upon it for
(159)
DISEASES OF THE SKIN.— NEOPLASTIC.
several weeks, this plan may be adopted with, the hope, if not the certainty, of obliterating
the dilated vessels. A more effective plan of treatment consists in the repeated injection of
a few drops of carbolic acid by means of a fine hypodermic syringe. When the growth is of
considerable size electrolysis may be employed with success, or red hot needles be thrust into
the tumor. Ordinary needles may be heated by means of a spirit lamp and used, but the
fine loop of platinum wire connected with a galvano-caustic battery is much preferable.
LUPUS VULGARIS.
Lupus is a chronic affection, presenting circumscribed, duU reddish patches of diseased
skin, which tend to ulcerate, and invariably leave a scar. Except in its severe forms there is
a notable absence of pain, itching and other subjective sensations. The disease runs a vari-
able course in different cases, and presents variations in appearance at different stages. The
most characteristic lesion is a small yellowish-red papule, which can frequently be noted at
the margin or in the vicinity of a patch. It is not present in all cases. Sometimes the dis-
ease begins as a dull reddish macule, which becomes slightly elevated and scaly as it increases
in si2e. This mUd or erythemato-squamous form of the disease may occur in one or in
several patches of irregular form. It creeps slowly over the surface attacked, and in many
cases disappears without ulceration. The cellular infiltration, however, usually produces a
certain amount of atrophy of the skin, and being absorbed, leaves a more or less distinct
cicatrix. When, as is commonly the case, the disease develops by the aggregation of small,
solid papules, the patches usually present an elevated, crescentic and sometimes a scalloped
border. Not unfrequently a prominent ridge of infiltrated skin will be seen surrounding a
tolerably smooth, and in some cases, a cicatricial center. As the papules of lupus increase in
size and become tubercular they evince a marked tendency to soften, and to form small ulcers,
especiaUj' at the advancing border of the patch. This now will present a reddened and scaly
surface, with numerous small crusts near the periphery and areas of cicatricial tissue in the
center. When the cellular growth invades the deeper portion of the skin ulceration is likely
to occur, sometimes assuming a serpiginous form, and often proving difficult to heal. The
face is the favorite seat of the disease, and the cheeks, upper lip and wings of the nose are
affected with great frequency. It also occurs on the scalp, trunk, and particularly on the
backs of the hands and fingers. The mucous membrane of the oral and nasal cavities may
be affected coincidently with the skin.
The disease is never congenital, and rarely, if ever, hereditary. It generally develops in
childhood or early life, although I have noted its first appearance in a man of sixty. The
sexes suffer with about equal frequency.
Lupus is regarded by some writers as being invariably a cutaneous manifestation of
scrofula. It surely occurs in some patients who are far from presenting signs of a strumous
diathesis. On the other hand, scrofulous abscesses often lead to an ulcerative process in the
skin (scrofuloderma), which surely ought not to be designated as lupus.
(160)
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LUPUS VULGARIS.
Diagnosis. The diagnosis of lupus is generally easy, but the tubercular and ulcerative
forms of the disease sometimes bear such a strong resemblance to syphilis that nothing but
experience in the treatment of the two diseases will enable one to decide as to the nature of the
case. The age of the eruption is of the greatest importance in arriving at a conclusion, since
the lupus is a disease of slow progress, while the cutaneous manifestations of syphilis develop
with considerable rapidity. If a patch of tubercles or an ulcer on the face is of doubtful
nature, it may be considered syphilitic if it is extensive and has developed within a few
months, while, if it has existed without much change for several years, it is assuredly lupus.
Treatment. Lupus is by no means the incurable disease which the majority of physi-
cians think it to be, provided the patient will submit gracefully to the proper treatment.
This is simple, though in many cases it is of necessity somewhat heroic. The quickest way
to cure the disease is to destroy it, and the scar resulting from treatment will probably be
much less unsightly than that which would, in time, result from the ravages of the disease.
Scarring, indeed, is inevitable in all cases save the most superficial. These mild cases may
sometimes be successfully treated by the employment of vigorous soap frictions, and the
application of highly stimulating ointments, but usually more severe measures are required.
In lupus we have a new growth in the skin, which manifests a marked tendency to spread
and invade healthy tissue. The main object of treatment must therefore be the destruction
or removal of this growth. When taken in its incipient stage this can be readily accom-
plished. If, however, lupus has increased to such an extent as to involve a considerable
amount of tissue, its successful treatment is by no means a trivial matter. Half-way meas-
ures are often worse than useless. In very many cases the attempts to heal the ulceration,
or remove the nodules by daily cauterization, have only stimulated the progress of the dis-
ease. It is better to do nothing than to irritate the part by applications which tend more to
inflame the healthy skin than to destroy the morbid growth. At the same time it is not
always necessary, and in lupus of the face it is often unadvisable to attempt to remove the
growth in a single operation. In treating lupus, our object is not only to remove the dis-
eased tissue, but to do so in such a manner as will occasion the least amount of disfigurement.
A relapse of the disease after an operation is considered by some surgeons to reflect discredit
upon the operator. But in the treatment of lupus of the face, I think it is far better to
remove the greater portion of the growth at the first operation, and to tell the patient that a
second or third operation will probably be required, in order to avoid, as far as possible, the
production of a disfiguring scar. Of course, if the patient desires the removal of the growth
in one operation, this can be accomplished, but in many cases I should not advise it.
Formerly, it was the custom to use the knife freely in the treatment of lupus, and no one
can doubt the success which was attained by this method, but the resulting scar was usually
large and deep. With the means now at our disposal, it is only in rare cases that we resoit
to the knife. When lupus invades the lower eyelid, as it freqently does, a plastic opei"ation
may be necessary, in order to fill up the gap made by the removal of the diseased tissue;
but when no such indications exist, a sharp spoon or curette is an instrument of far less ter-
pen
DISEASES OF TUE SKIN— NEOPLASTIC.
ror to the patient, and of far greater utility in the hands of the surgeon, than the knife.
WTiether we have a group of tubercles with an unbroken epidermis, or a patch of ulceration,
we can remove the diseased tissue by means of a curette with the greatest ease, and with a
slight amount of pain. Unless the patient is aged, or weak, or has very little courage, the
growth, if small or of moderate size, can be removed without the use of an anaesthetic. In
cases requiring anaesthesia, nitrous oxide gas is usually preferable to ether or chloroform.
The scraping operation can be performed much more quickly than excision, and while the
nitrous oxide may be safely inhaled for a half -hour or more, a few minutes of anaesthesia is
often all that is required, and then much time is wasted and trouble occasioned by the use of
ether.
In a number of cases I have resorted to the use of local anaesthesia with good effect. By
the use of an ether spray produced by means of a hand-ball, the part to be operated upon can
be kept in a half -frozen and almost insensible condition. The spray at the same time washes
away the diseased tissue as fast as it is loosened by the curette, leaving the surface clear and
thus rather facilitating the operation than otherwise. To one who has had no experience
with the use of the curette, the ease with which the morbid tissue can be scraped away is
quite surprising. The lupous nodules, although feeling firm to the touch, are much softer
than the surrounding skin, and are scraped out of the corium by the employment of very
little force. After some experience with this instrument, one learns to recognize the peculiar
sensation which is imparted to the touch, when the instrument comes in contact with per-
fectly healthy skin. Should no steps be taken further than scraping out the morbid growth,
a relapse is almost certain to occur, especially if the disease has existed for any considerable
time, and has invaded the deeper portion of the skin ; it is therefore always advisable to
cauterize the raw surface left after thorough scraping, or to apply some powder or paste,
which will be likely to destroy the vitality of the lupous cells which may remain. Of the
various caustics which have been employed, I have found the application of the chloride of
zinc to be most efficacious, but the pain which it occasions is a serious objection to its use.
The actual or thermo-cautery has been highly recommended, but I have seen lupous nodules
reappear so many times after its use, that I cannot recommend it. Pyrogallic acid in the
form of a twenty per cent, ointment, I have used as an application after scraping, and with
good results. A mixture of equal parts of arsenious acid and gum acacia, made into a paste
with a few drops of water, is very beneficial, inasmuch as it tends to destroy only the morbid
tissue ; but its use is followed by severe pain, which lasts for several hours. When the patch is
not of long standing, and is superficial in its seat, the application of iodoform after scraping
is the plan which I would recommend. It is painless, and like the arsenical paste, tends to
destroy the lupous cells and promotes the speedy healing of the ulceration. If, on the other
hand, the growth is of long standing, and the nodules are deeply seated in the corium, the
use of a cone of nitrate of silver is, in my opinion, the best adjuvant to the curette. The
point of nitrate of silver cone should be pressed firmly in different directions into the small
pits left after the removal of the nodules. This procedure will usually serve to destroy the
(102)
LUPUS ERYTHEMATOSUS.
LUPUS ERYTHEMATOSUS.
foci of the disease, which would otherwise certainly occasion a relapse in the course of a few
months.
After the removal of a patch of lupus, by means of the curette and the employment of
one of the applications already mentioned, the process of healing is usually speedy, and a
tolerably smooth cicatrix will result. A relapse may be looked for at any time during the
year follomng the operation, and should it occur, the morbid growth will appear in the form
of one or more brownish-red papules springing up at the edge, or in the midst of the cicatri-
cial tissue. A second operation then becomes necessary. But now it is comparatively a sim-
ple matter to dig out these foci of the disease by means of a curette of small size, and to
thrust in a cone of nitrate of silver.
Multiple puncture and linear scarification are methods of treatment which have beeu
highly recommended by European writers.
The latter is of the greatest value in cases of lupus of the face, where it is desirable to
leave as smooth and non-contractile a scar as possible. A very sharp kidney-shaped Icnife is
most serviceable for the purpose of scarification, and the cuts should be made as close to-
gether as they can be made and stiU remain parallel. The hemorrhage can be speedily
checked by the pressure of a wad of absorbent cotton, and the operation can be repeated in
a week or ten days, the parallel cuts being now made in a transverse direction. The pain
occasioned is inconsiderable if the knife is sharp, but in certain cases it may seem advisable
to previously rub the patch with oleate of cocaine, which deadens the sensibility of the skin
to a slight extent.
LUPUS ERYTHEMATOSUS.
Lupus erythematosus is an affection closely allied to lupus vulgaris, but commonly re.
garded as a distinct disease. It is characterized by the superficial character of the cellular
infiltration and the tendency to involve the sebaceous follicles. Unlike the common lupus
already described, this comparatively rare form does not tend to ulceration, although, when
the infiltration is sufficient to produce atrophy of the skin, a cicatricial surface results. The
name lupus erythematosus is an unfortunate one, since the common lupus {L. vulgaris) i.s
frequently superficial and erythematous, and confusion has arisen from a restricted use of
the adjective. The distinctive peculiarity of the variety of lupus now under consideration
being the involvement of the sebaceous glands, it would be far better to employ a term such
as lupus seiaceus or lupus acneiformis. Hebra, who first described this peculiar affection
of the skin in 1845, gave to it the name Seborrhoea congestiva, but later saw fit to class it as
a form of lupus.
The course of the disease is notably chronic. In rare instances it has been observed to
attack a large extent of cutaneous surface like an acute eruption, and to be accompanied
■nath severe constitutional symptoms. Frequently injudicious treatment or some other cause
may induce a patch of long standing to become acutely congested. Such an exacerbation of
(163)
DISEASES OF THE SKIN.— NEOPLASTIC
the disease is often coincident with the development of new lesions. As a rule the affection
exerts no perceptible influence on the general health of the patient. It is far more likely
than the common form of lupus to be accompanied by subjective sensations, such as burning
or even a slight itching. The disease usually makes its appearance in the form of small, red,
pin-head sized macules, which wiU not quite disappear on pressure. They present slight de-
pressions in the center, where the sebaceous follicles open upon the surface of the skin, or,
as is usually the case, these minute pits are filled with fine, adherent, fatty scales. These
characteristic primary lesions may be disseminated or grouped. In the latter case they form
patches of a dull reddish or violaceous hue, dotted with numerous whitish points, or covered
with fine adherent scales, which, when gently raised, show prolongations from the under
surface corresponding to the sebaceous follicles. The patches, of which there may be one or
several, are usually sharply defined. They may have an irregular outline, with primary
efflorescences scattered about the margin, or be circular in form, in which case they are apt
to become depressed as the disease progresses. The disease almost invariably attacks the
face. Occurring, as it frequently does, upon the bridge of the nose, and extending laterally
upon either cheek, the configuration of the patch is suggestive of a butterfly with outspread
wings.
Like the vulgar form, lupus erythematosus is sometimes associated with indications of
struma. It is more frequently met with in females, and in this sex is more apt to run a se-
vere course. It does not develop in childhood, as does lupus vulgaris.
Di.vGxosis. It is often quite difficult to distinguish lupus erythematosus from the super-
ficial or erythemato-squamous form of lupus vulgaris. But since the nature of these two
affections is almost identical and a somewhat similar treatment required in either case, the
differential diagnosis is not of the highest importance. Still, it is well to bear in mind, that,
whereas one affection has numerous white specks, or in some cases minute horny projections
upon the diseased surface, the other presents small papules, and at a more advanced stage,
tubercles, pustules and ulcers. The age of the patient may furnish a clew, as only the com-
mon variety of lupus is met with before the age of adolescence. A patch of chronic eczema
of the face, or rosacea, might be mistaken for erythematous lupus, and harm result from the
unnecessary use of caustic applications. But these affections have not the sharp border of
lupus, and while the former differs in being quite itchy, and perhaps moist at times, the
latter may be recognized by the development of tubercles and pustules.
Teeatment. In the treatment of this affection, whatever will improve the general
health of the patient should naturally be given ; it may be iron in one case, cod-liver oil in
another, and arsenic, strychnia, or phosphorus in others. The latter drug seems to have a
specially beneficial effect in lessening the congestion of the patches and promoting a tendency
to the cicatrization which sometimes occurs spontaneously. The internal use of the iodide
of starch in lupus erythematosus has recently been recommended upon good authority (An-
derson). I must say that I have failed to see any beneficial result in a number of cases in
which I have used it, although I regard it as a valuable remedy in combatting the strumous
(16-1)
SCROFULODERMA.
diathesis. Tlie local treatment is of the highest importance. Frictions with green soap )nay
be at first used to remove the scales and to promote absorption of the diseased tissue. Tar,
sulphur, and other stimulating applications may now be used with more or less effect, but a
better remedy is the constant application of adhesive mercurial plaster. In some mild cases
this will effect a cure. Generally, however, stronger applications are called for. A tincture
of iodine of double strength combined with an equal part of collodion, may be used as a
varnish, and renewed as often as it peels.
Where the infiltration is deep, a strong solution of caustic potash may be applied to
successive portions of the patch. In severe cases the dermal curette may be employed to
scrape away the diseased tissue, and the raw surface very lightly touched with the galvano-
cautery. When active congestion is present, caustics should be withheld until after a course
of soothing applications has put the skin in a less irritable condition. Otherwise, a mild
caustic may stimulate rather than decrease the affection.
The most efficient plan of local treatment which I have tried and the one suited to the
greatest number of cases consists in the application of pure carbolic acid.
SCROFULODERMA.
Synonym — Strumo-derma.
The term scrofula or struma has long been employed to indicate a peculiar constitutional
disease or condition of the system, which is usually inherited and manifested in early life by
the development of certain characteristic symptoms. The term has heretofore had a wide
application, and although many affections of the skin and internal organs which were for.
merly called scrofulous are now regarded as not in the least dependent upon this peculiar
diathesis, the term has still a somewhat indefinite meaning, and cannot be precisely defined.
The existence of the disease or diathesis cannot, however, be denied, and must be taken into
account in the treatment of ordinary affections, which occurring in scrofulous subjects are
apt to present a modified form.
The affections, which most frequently indicate a scrofulous habit, and especially concern
the dermatologist, are indolent inflammation, and caseous degeneration of the lymphatic
glands with the subsequent formation of peculiar cutaneous ulcers. This pathological pro-
cess is now frequently observed upon the neck of young persons, who often present other
manifestations of the scrofulous diathesis. These may be either a thick and doughy, or an
abnormally delicate and transparent skin, a tumefaction of the belly and a marked tendency to
chronic keratitis, otorrhoea and coryza. In the cervical region, the glands upon one or both
sides slowly enlarge and become firm or doughy to the touch. The skin at this time is unaf-
fected and there is little or no pain experienced by the patient. Nor is the glandular swelling
attended by the ordinary symptoms of inflammation. After this condition has existed for
many months, or perhaps years, a gradual suppurative softening of the glandular tissue
takes place, the tumors increase in size and become more or less painful. The skin now
(166)
DISEASES OF THE SKIN— NEOPLASTIC.
assumes a dull red or purplish, hue, and becomes thinner at one or more points until the fluc-
tuating abscess is partially evacuated by the formation of a sinus or ulcer. The discharge
which at first is sero-pumlent and mingled with caseous matter, gradually grows thinner,
and persists for a long time unless treatment is instituted. At last the skin heals and leaves
a puckered and disfiguring cicatrix. A number of glands iu the cervical chain are often
simultaneously affected. At a given time some of these may be discharging or covered by a
thin blackish crust, while others are unbroken or completely cicatrized.
Other forms of scr^iuloderma have been described in which disseminated pustules re-
sembling acne have developed upon the trunk, run an extremely indolent course, and left
numerous circular, depressed or " punched-out " cicatrices.
The cause of scrofula is an inherent tissue debUity, which, is usually transmitted from
one generation to another and is undoubtedly fostered by lack of pure air and proper food
and by the consanguineous marriages of affected individuals. In the negro race it is much
more common than among the whites. It has been recently claimed that scrofula and tuber-
culo-sis are intimately related and dependent upon an infection of the system by the bacUlus
described by Koch.
Diagnosis. Occurring upon the neck in connection with swollen glands the ulceration
of scrofuloderma is readUy recognized as such. Upon other portions of the body the scrofu-
lous ulcer which results from an infiltration of the skin by small celled mases of granulation
tissue is apt to be mistaken for a syphilitic gummatous ulcer. The co-existing evidences of
scrofula, or of syphilis, or a resort to specific treatment must often be relied upon to settle
the diagnosis.
Upon the backs of the hands a cheesy degeneration of the skin sometimes occurs as a
result of the inherited scrofulous taint, and bears a strong resemblance to lupus vulgaris.
There is, however, an absence of the small brownish nodules of lupus, and a marked ten-
dency of the patches to assume a verrucous condition.
Treatjiknt. The internal remedies which have found favor in the treatment of scrofu
loderma are cod-liver oil, iodine, especially in the form of iodide of iron or iodide of starch,
lime, phosphorus and chlorate of potash. In spite of their undoubted value in certain cases,
too much reliance should not be placed upon these drugs to the exclusion of a strict hygi-
enic regimen. Without proper food and plenty of open-air exercise, internal medication
will prove of little value.
The local treatment of scrofuloderma consists in the application of ointments or lotions
of mercury, iodine or iodoform to the hard and swollen glands, the excision or curetting of
softened and suppurating tumors, and the application of iodoform in powder and ethereal
solution to scrofulous ulcerations.
(166)
CHANCROID
CHANCRE.
CHANCRE.
PERIADENITIS,
SYPHILIS.
SYPHILIS.
Synonyms — Lues venerea — The Pox.
Syphilis is a specific, contagious disease, which is either inherited or acquired during life
through the absorption of a poisonous secretion from a person already suffering from the
disease. The acquired form invariably manifests itself at the outset by the development of
a peculiar lesion upon the skin or mucous membrane at the point where inoculation has taken
place. The evolution of syphilis is slow and irregular, often lasting for a lifetime, but in
many respects the disease bears a resemblance to the acute exanthemata. It sometimes runs
its course in a few years, leaving the patient apparently in perfect health, and although it
commonly occurs but once in a lifetime, there are numerous authenticated instances of syph-
ilitic re-infection.
The nature of the so-caHed virus, or infectious principle of a;n inoculable syphilitic
secretion, is as yet unknown. How it produces the characteristic symptoms of the disease
is equally obscure. Various experimenters have discovered by microscopical observation
various fungi, corpuscles and bacterial germs which they have thought to be the source of
infection, but their views have so far failed to meet with general approbation, and we are
forced to admit that we only know the infecting principle of syphilis from a study of its
effects.
The blood of syiDhilitic patients throughout the earlier period of the disease or the
secretion taken from the surface of the moist syphilitic lesions is well kno^vn to be capable
of producing syphilis in a person who has not already been inoculated, provided it is applied
to a surface capable of absorbing the same. This inoculation has been perfonned intention-
ally with a positive result and the unintentional transmission of the disease in this manner
may be studied in very many cases. Upon an unbroken epidermis the blood or virulent
secretion may be applied without the production of a primary syphUitic lesion, such as fol-
lows successful inoculation. Moreover, the physiological secretions of a syphilitic subject,
such as saliva, urine, milk and semen, as weU as pathological secretions, such as pus unmixed
with blood, appear to contain no virus, and hence may be inoculated without result.
The initial lesion or chancre, which develops at the point of inociilation, is most fre-
quently met with upon the genitals, but may occur upon any portion of the skin or mucous
membrane. Extra-genital chancres are not unfrequently observed upon the fingers, lips and
within the oral cavity and upon the breasts of nurses. This lesion assumes a variety of clini.
cal appearances depending more or less upon its location, and may consist of a dry or moist
papule, or assume the form of an ulcer. In all cases the lesion is characterized by mure or
less induration of the subjacent tissue which serves to distinguish it from the chancroid or
"soft chancre," which is generally regarded as a local venereal sore and incapable of infect-
ing the patient with a constitutional disease. The initial lesion of syphilis appears usually
three weeks or thereabouts after an impure intercourse, but this period of incubation may
(167)
DISEASES OF THE SKIN.— NEOPLASTIC.
vary between two and eight weeks. In this respect the lesion differs notably from the chan-
croid which is commonly noticed within a day or two after inoculation.
Following the development of the chancre the neighboring lymphatic glands become
more or less enlarged and indurated within two weeks. One or more glands may be notably
affected and readily felt beneath the skin. They are not usually painful and rarely suppu-
rate. About a month later a general engorgement or induration of all the subcutaneous
glands may be observed. Those situated in the neck along the posterior border of the ster-
no-mastoid muscle and those along the inner surface of the arm, together with the inguinal
glands can be most plainly felt.
At this time there is apt to occur a group of new symptoms, consisting of a slight rise
In temperature (the syphilitic fever), an intense and prolonged headache, a painful con-
dition of certain of the larger joints and an outbreak of a macular eruption upon the
skin. During the next few months the macular eruption usually merges into or is suc-
ceeded by a papular, pustular or disseminated tubercular eruption or a succession of eruptions
may appear upon the skin. With the earliest eruption there is usually a soreness of the throat
with perhaps a few erosions upon the soft palate. The arthritic pains are apt to be quite
troublesome, espciaUy at night. The hair of the scalp becomes loosened to a greater or less
degree, and often falls in considerable quantity. A month or two later mucous patches are apt
to appear upon the lips, tongue or pharynx, and also about the anus. Sometimes these are
noted on the sides of the scrotum and the under surface of the penis. An acute iritis occa
sionally occurs at this period.
All of these symptoms may not be observed in the same patient, but while one suffers
especially from eruptions upon the skin, another will complain more of ulceration of the
mucous membranes, of falling of the hair or of rheumatoid pains. The general health of
the patient is usually perceptibly impaired, although in a majority of cases his usual avoca-
tion is not interrupted to any extent. Before the end of six months or a year, especially if
judicious treatment has been instituted, the symptoms of the disease usually abate or entirely
disappear. But relapses of the various symptoms at lengthened intervals are to be expected
for at least another year, although they do not necessarily occur. The cutaneous eruptions
gradually loose their disseminate and symmetrical character the farther they are removed
from the date of the initial lesion, and the other symptoms become less pronounced in char-
acter.
During the next few years, or it may be fifteen or twenty years after infection, a some-
what different class of lesions is commonly observed. These affect not only the skin and
mucous membranes, but the deeper connective tissues, the bones and the various internal
organs. These later lesions are always localized, hyperplastic or gummatous in character,
and evince a marked tendency to destructive ulceration. A somewhat arbitrary distinction
is often made between the secondary stage of syphiUs in which the lesions are superficial and
the tertiary stage in which the lesions are more deeply seated, but it must be remembered
that superficial cutaneous lesions often occur very late in the course of the disease, while in
(168)
STPEILIS.
certain cases (galloping syphilis) tlie most severe symptoms, including affections of bones and
internal organs, are met with a few months after infection. StUl it is often convenient to
make certain divisions in the conrse of syphilis, and the following stages or periods will
generally be found to correspond to the natural history of the disease.
1. Period of Inoculation. From the absorption of the virus to the appearance of the chancre.
2. Period of Imasion, or '■^ Second Inoculation.''^ Primary SypTiilis. From the develop-
ment of the chancre to the outbreak of constitutional symptoms.
3. Period of Efflorescence. Secondary Syphilis. From the appearance to the disappear-
ance of symmetrical eruptions, and other indications of blood-poisoning.
4. Period of Decline. Tertiary SypJdlis. From the cessation of symmetrical manifesta-
tions ad infinitum.
For a complete description of the various eruptions occurring in the course of the dis-
ease, the reader is referred to the author's work entitled "Photographic Illustrations of Cu-
taneous Syphilis."
Treatment. In a large proportion of cases, syphilis will run its course and leave the
patient in a healthy condition, even though no special treatment is instituted. This is
proven by the number of men and women in ordinary health who have contracted the disease
and recovered from it without being conscious of the fact. While a weak constitution and
habits of dissipation tend to aggravate the symptoms of syphilis and predispose to certain
evils which are apt to follow in the train of the disease, a sound constitution and careful
attention to the fundamental laws of health will enable most syphilitic patients to recover in
time without recourse to any specific treatment. Considerable stress should be laid upon
this point since it is a too prevalent idea in the professional mind that a certain routine treat-
ment by drugs is absolutely essential in the cure of this disease, and too much reliance is
often placed upon the action of certain specific remedies. These are of value beyond a doubt
but they are not indispensable.
The treatment of syphilis varies according to the stage of the disease and the character
of the symptoms. In most cases it will be found advisable to combine constitutional and
topical remedies.
In primary syphilis we have the initial lesion or indui'ated chancre to deal with, and the
question arises, "Can constitutional infection be prevented at this early stage of the dis-
ease?" If the view of Bumstead and others is held, viz., that the initial lesion itself is
already an evidence of constitutional infection, the question must be answered in the nega-
tive. But if, on the other hand, we accept the doctrine taught by Otis and others, viz., that
the chancre is a local disease which only infects the system through the medium of the lym-
phatic vessels after a lapse of several weeks, it must be admitted that its complete destruc-
tion at the very outset and before the nearest glands are involved, would save the patient
from constitiitional disease. The experience of many observers for many years has shown
that the most thorough cauterization of a hard chancre does not afford immunity from con-
stitutional infection. A complete excision of the indurated mass on the other hand has
(169)
DISEASES OF THE SKIN— NEOPLASTIC.
apparently succeeded in a small proportion of cases in affording this desired immunity. But
as the efficacy of this measure is still an open question, it cannot be recommended, and
ouo-ht not to be attempted save in those cases where an unmistakable hard chancre is seated
upon a redundant prepuce, in which case circumcision would be advantageous, even if it
faUed to prevent the constitutional manifestations of the disease.
The propriety of administering mercury in the primary stage of syphilis is another
point upon which syphilographers differ. Since in many cases there is a doubt as to the
true character of the lesion it is often advisable to wait until this important point is settled
by the outbreak of constitutional symptoms. The delay is never productive of any serious
harm, while the administration of mercury at this stage may prove unnecessary in case of a
doubtful diagnosis of the lesion. Moreover, the premature use of the drug tends to i:)Ostpone
the evolution of the secondary symptoms, modifies their character, so that they are not
readUy recognized, and often leaves the patient in anxious doubt as to whether he has really
had syphUis or not. This condition of mind may interfere with matrimonial prospects, may
render a nervous patient hypochondriacal and not infrequently prove worse than the disease
itself. The belief that the administration of mercury at this stage does harm I cannot ac-
cept, and in a case where there was no possible doubt as to the genuineness of the initial
lesion, and where it seemed probable that the patient would remain under observation for
several years I should advise, in the interest of the patient, the early institution of specific
treatment.
Topical applications in the treatment of chancre, i. e., an indurated chancre, are often
unnecessary. The lesion is rarely productive of any physical discomfort, and may often be
left to run its coxirse and gradually disappear. It ought never to be cauterized since this
procedure is both painful and unprofitable. Calomel or iodoform may be sprinkled over the
surface if this is abraded or ulcerated, and the lesion should be kept scrupulously clean.
The indui-ation of the chancre and neighboring glands wiU often disappear more speedily if a
five per cent, oleate of mercury is rubbed into the skin, but the result is not always worth
the time and trouble.
In secondary syphilis we have to deal with a group of characteristic symptoms
which indicate a condition of systemic poisoning. Active measures are now usually de-
manded by the patient, whatever the physician' s views may be respecting the sufficiency of
expectant treatment. At this stage it is advisable to adopt a combination of internal and
topical treatment, which experience has shown to be of great value in controlling the severity
and hastening the course of the various symptoms, and in preventing, to a certain extent,
the subsequent occurrence of undesirable sequels^. The internal treatment consists mainly in
the administration of such remedies as are believed to have a specific action in the cure of
the disease, and of these mercury has long held a prominent position. The following propo-
sitions embody the result of my own study and experience in the use of mercury :
I. In the Medicinal Treatment of Syphilis, Mercury is undoubtedly our most Valuable
Remedy. The beneficial results which follow the judicious employment of this drug are
(170)
S. PAPr LOSUM.
S. ULCERATIVUM.
1 ^1 I'l- IH'IJ 1 ' 'SI ' M .
SYPHILODERMA.
SYPHILIS.
sucli as to convince any unprejudiced observer as to its eminent virtue. As, probably, no
reader will differ with me on this point, no argument is necessary.
II. Mercury is an Overrated Memedy. The fact that a remedy will do much is no indica-
tion that it vdll accomplish everything that may be desired of it. Mercury will lessen the
manifestations and shorten the course of syphilis in most cases, but it will not always jiro-
duce a speedy and beneficial effegft, as many physicians have been led to believe. Some of
the worst cases of syphilis which I have observed in my practice have ocurred in patients
to whom I gave mercury persistently for one or two years, and I must admit that in these
cases I have faUen into the prevalent error of overestimating the curative action of the drug.
If the profession generally were more strongly impressed with the great value of hygienic
and tonic measures in the treatment of syphilis, and were less inclined to confide solely in
the specific action of mercury, I am convinced that their patients would receive a far greater
amount of benefit. We all know that remedial agents of little or no power often acquire a
fictitious value by reason of the fact that patients improve during their administration.
This post-hoc fallacy is rarely thought of in connection with the administration of mercury
in syphilis, because we know that the drug is not inert, and have ample proof that it can
and does accomplish a great deal ; but it is well to bear in mind that the improvement which
takes place in our syphilitic patients when treated secundum artem is not wholly the effect
of the mercury which has been administered, but is due in great part to the existence of
a natural vis medicatrix.
III. Mercury is not Essential to the Cure of Syphilis. This disease is one which,
like the other exanthematous affections, tends to run its course. It may be severe, and in
rare instances it terminates fatally. But in the majority of cases of the acquired form it is a
far less malignant disease than it is commonly supposed to be, and when the patient is of
sound constitution and the infection is not of unusual virulence, it usually runs its course
without producing any permanent damage to the health of the patient. I have treated for
two or more years without mercury several patients who expresed an objection to the use of
the drug, and I must say that they apparently did as well as other patients treated in the
usual manner. Some will claim that these patients will be very liable to suffer from severe
lesions in later years, but of this I have strong doubts. Indeed, I have seen so many hale
men of advanced years who have certainly had syphilis in their younger days and received
no specific treatment, that I cannot believe that a cure of the disease is dependent upon the
use of mercury.
IV. The Internal Admiinistration of Mercury is preferaMe to Inunction., Vapor Baths,
or Hypodermic Injection. I am decidedly in favor of the use of mercurial ointments and
lotions for the local treatment of cutaneous symptoms, but for the cure of the constitutional
disease a somewhat extended trial of mercurial inunction has led me to abandon it as pos-
sessing many objectionable features and few advantages. It is but just for me to say that
my experience with vapor baths and hypodermic injections has been very limited. The
advantages that have been claimed for them, as also for inunction — viz., that they do not
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DISEASES OF THE SKIN.— NEOPLASTIC.
occasion irritation of the intestinal tract — are arguments in their favor to those who employ
mercury internally in large doses ; but they possess no advantage over the method of inter-
nal treatment which I shall presently recommend, and certainly cannot claim the merit of
simplicity.
V. The Amount of Mercury usually given to SypMlitic Patients is unnecessarily large.
From the time when the beneficial effect of mercury was estimated by the pints of saliva
which dribbled from the patient's month, there has been a constant tendency towards a dimi-
nution in the dosage of this drug. At the present day it is considered the proper thing to
give as much mercury as the patient can bear without showing symptoms of salivation, and,
as nearly every writer on syphilis gives explicit directions for the treatment of salivation, it
is a just inference that this undesirable effect of mercury is occasionally met with ia their
practice. "While I admit that certain patients are far more liable to become salivated by
mercury than others, and that in iritis and under certain other conditions it may be deemed
advisable to " push" the remedy, I must assert my belief that in the vast majority of cases
of syphilis the very best effects of mercury may be obtained by the employment of doses
which will not involve the slightest danger of salivation.
There are many patients who will take a tablespoonful of a remedy when a teaspoonful
has been prescribed by their physician, on the absurd principle that if a small dose does
them good a larger dose will produce a corresponding amount of benefit ; and there are many
physicians who seem unable to disabuse their minds of the fallacious idea that within cer-
taia limits the curative effect of every drug is in direct i-atio to the amount which is adminis-
tered. I have no faith whatever in the administration of mercury in infinitesimal doses, but
my experience has led me to the belief that a daily half-grain or grain of blue mass, or the
protoiodide of mercury in divided doses, will do quite as much if not more good than the
grain and a half or two grains daily which is the more common dosage.
VI. In the Internal Use of Mercury its Local Irritant Effect should be avoided. This
can be accomplished by a reduction of the size of the dose, and its more frequent administra-
tion if necessary, and by the employment of milk-sugar triturations. Regarding the choice
between metallic mercury and its numerous salts I am not prepared to speak. My own pref-
erence is for the protoiodide, which, given in the form of a trituration and in the doses which
I have commended, will rarely be found to occasion gastric or intestinal disturbance of any
account. In the latter stage of syphilis I have followed the custom of changing from a mer-
curous to a mercuric salt, from the green iodide to the red iodide, e. g., but, as the proto-salts
are less irritant in their local action, I see no good reason why the green iodide should not be
continued throughout the course of the disease. In my own experience I have never observed
any benefit result from a combination of various salts, as recommended by Bumstead, or
by a frequent change from one preparation to another.
VII. The Duraiion of Mercurial Treatment should vary according to the Severity of
the Case. When syphilis began to be described, at the close of the fifteenth century, its
very worst forms were naturally observed and reported. The severest cases soon came
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SYPEILIS.
to be regarded as a type of the disease, and in our text-books of the present day the descrip-
tion of syphilis rarely corresponds with the average case in practice, but is mainly a descrip-
tion of the severer and comparatively uncommon phase of the disease. There are cases of
mild syphilis, and there are cases of severe syphUis, and, although I do not coincide with M.
Diday in his opinion that mild syphilis does not demand mercurial treatment, I do protest
against the common practice of treating all cases of syphilis upon a routine plan. Who
would think of venturing upon the unqualified statement that scarlet fever should be treated
for so many days or weeks ? No one ! And yet we find many writers on syphilis layino-
down the absolute rule that the disease must be treated during a certain specified number of
months or years, without even hinting that for various reasons one patient may not require
so much treatment as another.
When I say that there are cases of scarlet fever so mild as to require no treatment, the
statement passes without objection ; but when I hint that syphilis may occur in a mUd or
benignant form, I hear expressions of dissent on all sides. From the text-book rises that
horrible phantom of possible syphilis, and the awe-stricken beholder exclaims, " Oh ! the
idea of applying the term benignant to a disease which may eat into the bones, cause paraly-
sis, blindnsss, or sudden deafness, or carry away the nose of the patient ! ' ' The question is
not whether the disease is always benignant, but whether it is commonly benignant. There
are cases of syphilis which demand two years, or perhaps five years of treatment, but it
seems to me to be utterly unreasonable to fix a certain time as the duration of treatment for
all cases. When the early symptoms of the disease are slight, and disappear speedily under
treatment, I deem it quite unnecessary to continue the use of mercury for two or three years,
with an idea of thoroughly eradicating the disease, and thus preventing subsequent manifesta-
tions. The late lesions of syphilis may and frequently do occur after a prolonged and thor-
ough administration of mercury. I doubt if they are more likely to apjjear in those cases in
which mercury is given merely with a view of removing the symptoms of the disease in its
early stage.
My own practice is to give mercury in every case diiring the existence of any symptoms
of the diseaae, whether it occurs early or late. In the early period I continue the use of mer-
cury for six months after the last symptom has yielded, and I do this partly in deference to
the opinion of eminent authority and the commonly accepted teachings. I then stop the
administration of the drug and await further developments. If symptoms reappear, I resort
again to the use of mercury, and continue it this time for two or three months after their dis-
appearance. In late syphilis I give mercury for the purpose of subduing symptoms which may
occur, and stop its use as soon as I have accomplished this result. In so doing, I believe I am
practicing in accordance with the old adage "enough is as good as a feast."
It is a prevalent belief among authoritative writers that iodide of potassium has no actual
curative eiiect in the treatment of syphilis, but merely the power to cause the disappearance
of certain symptoms, and, furthermore, that it has little or no value in the early stages
of the disease. I dislike to differ in opinion from the weight of authority, particularly when
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DISEASES OF THE SKm— NEOPLASTIC.
T have no convincing proof to bring to the support of my own views, but I must express my
belief that iodide of potassium, though inferior to mercury, has still a curative effect upon
syphilis, and that in the early stage it is an invaluable therapeutic agent in the relief of cer-
tain symptoms. Mercury in secondary, and iodide of potassium in tertiary syphilis, is the
Teaching and practice of many physicians. For my part, I believe that there is no stage of the
disease when both remedies are not calculated to do good. In many cases of chancre charac-
terized by a massive induration I give iodide of potassium, and apparently with the effect of
reducing its size. In the stage of eiflorescence I must admit that the drug has little or no
effect upon the cutaneous manifestations. StiU, if it be true, as has been claimed, that the
administration of the drug causes an increase in the number of blood corpuscles, it has the
same claim as mercury to be ranked as a "tonic remedy." In one or two cases of extensive
mucous patches, with ulceration of the lips and tongue, I have seen a rapid disappearance of
the lesion follow the administration of iodide of potassium when mercury had been taken by
the patient for several weeks with little or no effect. But it is in the cure of the cephalalgia
and arthritic pains which are so commonly associated with the first outbreak of syphilis that
iodide of potassium displays its remarkable power, and I am at a loss to know how these
symptoms are alleviated by physicians who believe in withholding the drug until the advent
of gummy tumors or late ulcerations.
Of the great value of the drug in late syphilis I need not speak. I vaQ. venture, how-
ever, to remind the reader that its power is often exerted in a most brilliant manner when
its administration is preceded by a short mercurial course. I can recall cases of syphi-
litic orchitis in which the drug has seemed to have very little effect. Mercury has been sub-
stituted for it, and still no marked change has followed. But, upon resuming the iodide of
potassium after the mercury, the swelling of the testicle has lessened with surprising rapid-
ity. In order to ascertain the effect of either drug, I deem it advisable to give mercury and
iodide of potassium separately. It is more instructive to the physician to follow this plan,
although the " mixed treatment " may be equally beneficial to the patient. The iodide is
best prescribed, I think, in an aqueous solution, a cubic centimetre containing a gram, or a
minim representing a grain of the drug.
Iodide of potassium is a remedy which no patient ought to be compelled to take for any
length of time. It does its work quickly or not at aU, and when unnecessarily continued is
sure to do harm. This is especially true in those cases in which immense doses are adminis-
tered. It is undoubtedly true that a five-gram dose will sometimes accomplish a result
when four grams would produce no effect, and even larger doses may sometimes be re-
quired ; but for every case of syphilis which I have seen benefited by immense doses of the
iodide I have seen at least two cases in which the large doses have done harm. Several phy-
sicians have told me of cases of syphilis in which the sjTnptoms were frightful to an extreme
degree, and could only be kept in abeyance by the continued administration of immense
doses. I may say here, what I thought unnecessary to say to them, that my own experience
prevented my placing faith in the correctness of their representations. I cannot believe that
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SYPHILIS.
there are such cases, and I am sure that in some instances tlie symptoms of lodism have been
mistaken for the effects of syphilis. In one or two hospitals I have seen wretched creatures
dying slowly from the combined effects of syphUis and heroic doses of potash, and have often
thought that, if the amount of money paid out for this drug had been expended in furnish-
ing a decent beef -steak or a little pure country air, the chances for the patient's recovery
Avould have been vastly increased. I do not deny the value of large doses of the iodide of
potassium in certain cases, but I protest against the continuance of such doses when nothing
but harm results.
Iron is a remedy which, in the treatment of syphUis, is of very great value. Though
rarely mentioned by syphilographers as being specially adapted to the treatment of this dis-
ease, it deserves, in my opinion, to be ranked with mercury and iodide of potassiiim. I wiU
not claim for it the antidotal or directly curative effect which is usually ascribed to mercury,
nor assert that it has any marked influence upon the outward symptoms of the disease ; but
its power to combat the anaemia which is invariably present in the early stage of syphilis
renders it a most valuable adjunct to mercury. I usually prescribe it for patients presenting
a chancre, or initial lesion of syphilis, and give it as a routine remedy during the period of
efflorescence, or so-caUed secondary syphilis. I believe that it not only elevates the tone of
the system, and thus renders it more capable of resisting the syphilitic attack, but that it
also tends, in a slight degree at least, to lessen the probability of subsequent manifestations.
In the weakened state of the system which is so often associated with late syphilis, the value of
iron is too well known to require even a mention, but in the early stage of the disease its value
appears to be unknown or unappreciated, and I cannot but lament the prevalent belief that
in early syphilis the whole duty of the physician is simply to give mercury. The tinctui'e
of the chloride of iron is the remedy which I usually employ, and I would recommend it,
not only for its tonic effect, but for its efficacy in counteracting the slight diarrhoea which
often results even from very small doses of mercury. A daUy dose of ten or fifteen drops of
the tincture will usually suffice to produce the latter result, and seems to me to be preferable
to the common custom of combining an opiate with the merctu'ial.
Cod-liver oU is a remedy which is not unf requently of service in the treatment of syphOis.
When an individual with a decidedly strumous diathesis becomes infected with this disease,
its symptoms are apt to be severe and prolonged, and their amenability to the ordinary mer-
curial treatment is greatly lessened. Indeed, in these scrofulo -syphilitic subjects the adminis-
tration of mercury sometimes fails to produce a beneficial effect, and if pushed to any extent
is liable to do harm. The use of cod-liver oil, alone or in connection with iodine, is more
likely to be productive of good results in these cases. It often prepares the patient for a
systematic mercurial treatment, which would not be tolerated if employed at the very outset.
In late syphilis, of an ulcerative type, I have repeatedly seen mercury fail to do good at first,
while after the administration of the oU for a month or more it has accomplished aU that
could be expected from its use.
Limited space forbids a discussion of the hygienic measixres which are of value in the
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DISEASES OF THE SKIN:— NEOPLASTIC.
treatment of syphilis, but I wonld remind the reader that in many cases an over-indulgence in
alcoholic drinks and other habits of dissipation, improper food, and lack of out-door exer-
cise, hare produced a condition of mind and body which complicates the syphilis, and for
which mercury is not a specific. Teachers of medicine strive to impress upon the minds of
pupils the necessity of treating the disease, and not merely its symptoms. Were I able, I
would impress upon the mind of every physician the duty of treating the patient, and not
simply his disease. In the use of anti-syphilitic remedies I am certain that we shall achieve
the best results if we do not become absorbed -inth the idea that we are treating a patient
with syphilis, but bear constantly in mind the important fact that we are treating a 'patient
with syphilis.
LEPRA.
Synonyms — Mhphan tiasis Qrcecorutn. — Zieproty,
The leprosy of the present day, occurring in Oriental countries and elsewhere, undoubt-
edly afflicted the children of Israel in the time of Moses. The Scriptural account of the dis-
ease, however, as recorded in Leviticus, is for the most part unintelligible, and it is probable
that at the time when it was wi-itten a number of chronic and contagious affections were con-
founded with true leprosy. In later centuries this mistake has been repeatedly made, and
the numerous leper-houses established throughout Europe at the time of the crusades, doubt-
less contained a large proportion of syphilitic, psoriatic and other patients. In glancing at
the history of leprosy, we find not only a confusion of diseases, but a confusion of names.
Suffice it to say that the term Elephantiasis Grsecorum is now discarded, and the term Lepra
(unfortunately applied by some writers to a form of psoriasis), is generally adopted in Ger-
many, France and America as the synonym of leprosy.
True leprosy is now met with not only in distant parts of the world, but also in our own
country. Wherever found the disease presents the same general characteristics. In Egj^pt,
where it doubtless originated, and where it has prevailed for several thousand years, it still
occurs. In Syria, India, China and Japan, it is quite common. In Europe it is endemic,
chiefly along the shores of the Mediterranean and in Norway, although occasional cases are
met with from time to time in many of the larger cities. In the West Indies and portions ol
South America it is also common, and in the Sandwich Islands it has increased rapidly in
recent years and now affects a large proportion of the native population. The island of Mo-
lokai has been set apart as a home for the leprous subjects of the kingdom, and several
thousand cases have been admitted to the asylum which was founded there in 1865. Coming
nearer home, we find the disease existing among the Chinese in California, among the Nor-
wegians in Minnesota, among the French and negroes in Louisiana, and among certain French
Canadians in New Brunswick and Nova Scotia.
During the past ten or fifteen years there have constantly been from one to a half-dozen
or more cases of leprosy in the hospitals of New York City, while other cases have been re-
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LhFRA.
l)orted from Boston, Philadelphia, Baltimore and other cities. Most of these cases have
occurred among sailors or others, who have spent considerable time in the tropical countrieii
where leprosy is common and there contracted the disease. In New York there has occurred
but one case in a person who had not been outside of the State, and in this case the origin of
the disease could not be explained.
There are three forms of leprosy based upon the predominance of certain lesions or
symptoms, viz. : the tuberose, the macular, and the ancesthetic. Frequently both macules and
protuberances co-exist in the same patient. Anaesthesia in greater or less degree is rarely
absent in advanced cases, but it may occur, as the sole cutaneous lesion, neither macules nor
tubercles being present. In some text-books but two forms are described, the macular and
the tubercular.
Like syphilis, lepra is a constitutional disease, the cutaneous manifestations of which,
though highly interesting, are of but secondary importance. A gradual decline in health
asuaUy precedes the earliest characteristic indications, which may be faint brownish patches
of discoloration or small aggregated tubercles. In case of tuberose leprosy the first unmis-
takable signs are usually seen upon the face. Tubercular thickening invades the lower half
of the forehead, and as the tubercles increase in size and become tuberous, the patient's face
assumes a very characteristic leonine expression. The nose and ears are very apt to be the
seat of similar protuberances.
The nerves undergo a remarkable change in lepra, the larger trunks of the extremities,
as well as the finer branches supplying the skin, becoming thickened and degenerate. The
ulnar nerve, in particular, can usually be felt enlarged and hardened. The fingers and toes
and other portions of skin supplied by these affected nerves suffer as a natural consequence.
In an early stage of the disease they are hypersesthetic, but as changes in the nerves pro-
gress, they become numb and almost lifeless. Ulcers form, which are healed with difficulty.
In severe cases the bones of the extremities become carious, and one by one the rotting
phalanges fall off and leave disgusting stumps. The tubercles upon the face and elsewhere
develop slowly, and though generally permanent, they sometimes decrease in size and disap-
pear by absorption. New ones in greater number usually take their place, and the disease
goes from bad to worse until the strength of the patient fails.
It is an extremely difficult matter to determine beyond all doubt whether leprosy spreads
only through hereditary transmission or only through direct contagion, or in both of these
ways. The disease is considered by many who have had the best opportunities for studjing
it, to be hereditary in some cases, and at the same time capable of being propagated through
inoculation.
The theory that leprosy may originate from certain endemic influences, such as climate,
diet, etc. , does not appear to have a very substantial foundation. When the disease once
becomes prevalent in a community where vice, ignorance and filth abound, it usually tends
to increase, but it is far from being a highly contagious disease, as is commonly imagined.
Physicians and hospital nurses need have no hesitancy in caring for leprous patients, pro-
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DISEASES OF THE SKIN.— NEOPLASTIC.
vided the ordinary precautions are taken which are usual in the treatment of syphilitic pa-
tients. The fear of the disease ever spreading through an intelligent community appears to
me to be without foundation.
The opinion that leprosy results from a germ or parasite to be found by careful micro-
scopical examination in the affected tissues is one which is now held by many eminent
authorities. This germ is kno^vn as the "bacillus leprae." The rod-like micro-organisms
are found in the cells of a leprous neoplasm but not in the blood of leprous patients.
Diagnosis. The diagnosis of a case of leprosy is more or less easy, according as the
disease is more or less developed. In an advanced stage, its peculiar features proclaim the
diagnosis at a glance, but in its incipiency it may pass unsuspected for months or years,
especially when met with in a country or region where it does not prevail. The earliest
symptoms are usually a gradual loss of strength from no apparent cause, chillj' sensations,
vague pains, and numbness of the extremities. Later the disease is characterized by the de-
velopment of numerous brownish patches upon the extremities, nodules above the eyebrows
or about the ears, and tracts of anaesthetic skin particularly on the hands and feet. The
diseases \vith which leprosy might be most readily confounded are syphilis, lupus, leuco-
derma, scleroderma and morphoea ; but the features of a case, if at all well marked, will
usually proclaim its nature as soon as the diagnosis of leprosy is suggested.
Lepra tuberosa may bear a resemblance, at first glance, to tubercular syphilis, the fore-
head being a favorite seat of either disease. But the infiltration of the skin in leprosy is
more diffused, the protuberances are of variable size, often larger in the center of the patch,
and always of a dull, bronzed hue. The syphiloderm in this locality presents small, hard
tubercles of a brownish-red color, arranged often in a circular or crescentic form, tending to
ulceration and sometimes enclosing a smooth area. Lepra maculosa may simulate leuco-
denna, both in form and color, but the patches in the former are never perfectly smooth as
in the latter affection.
Treatment. Leprosy is a disease which is commonly regarded as practically incurable,
since there is no remedy or plan of treatment which can be adopted with the certainty of
restoring the patient to perfect health. And yet many cases improve to a greater or less
extent under treatment, and some have been reported in which an apparent cure of the dis-
ease has been effected. My own experience in the treatment of this disease, though a com-
paratively limited one, has convinced me that judicious measures will ameliorate the condi-
tion of the patient in a marked degree, and I am by no means disposed to admit that the
disease is an incurable one.
The first step in the treatment of leprosy is to remove the patient, if possible, from the
locality in which the disease has been contracted. Hutchinson has reported the case of a
woman whose parents had always resided in England, and who contracted the disease in a
severe form during a twelve years sojourn in Jamaica. She became apparently free from all
symptoms after her return to England, and during a period of twenty years there was no
return of the disease, and the woman considered herself perfectly well. A mere change of
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LEPRA.
residence could not be expected to effect a cure, since leprosy is known to run its course to a
fatal termination in almost every climate ; but a change of diet and habits is doubtless a fac-
tor of far greater importance. In this case Hutchinson attributed the cure mainly to a ces-
sation of a diet composed largely of unwholesome fish, which in leprous countries is supposed
by many to be an active cause of the disease. The next step is to place the patient under
the best hygienic conditions, and to treat the symptoms of the disease on general principles.
Where ulceration of the extremities has taken place, the sores should be kept scrupulously
clean, and dressed with some slightly stimulating application, such as balsam of Peru. For
the pain, which is usually annoying in an advanced stage of the disease, morphia may be
given. Stretching of the ulnar nerve under ansesthesia has been resorted to in some cases of
leprosy, with a view to restore its functions. The operation seems to have i)roduced at least
a temporary benefit in a considerable number of cases. The thickening of the nerve has
been lessened, and the anaesthetic portions of the skin supplied by it have been restored to
sensibility. As regards internal treatment, many remedies have been vaunted, but as yet no
specific has been found. There are certain balsams and oils, which, if used for a length of
time, produce a favorable change in the condition of the patient, though it cannot be said
that they will always cure the disease. Chief among these are gurjon balsam and cashew
and chaulmoogra oils. The former is used by British surgeons in India and other tropical
localities, with good results. For internal use, an emulsion is made of equal parts of the
oil and lime water, and administered in half-ounce doses, twice daily. As an external appli-
cation, the oil is mixed with three parts of lime-water, and with this the whole body is
thoroughly rubbed. Under this plan of treatment patients in an advanced stage of leprosy
imijrove in health, the ulcers heal, the tubercles soften and disappear, and the ansestheiic
parts resume their sensibility.
Chaulmoogra oil (expressed from the seeds of gynocardia odorata) appears to be the most
efficient remedy which has been used in the treatment of leprosy, although it has seemed to
have little or no effect in certain cases. One patient with macular leprosy who was under my
care for about a year improved steadily under daily drachm doses of the oil. The brownish
patches upon face and trunk entirely disappeared, his general health improved, and at last,
report he claimed to be entirely free from all evidence of the disease, save the contraction
and numbness of the fingers. One case of macular leprosy in a boy of nine, which I had the
repeated opportunity of seeing, manifested a considerable degree of improvement under an
ordinary anti-syphilitic course of treatment.
The prognosis of leprosy, as is evident from the foregoing, is unfavorable. In the tuber-
cular, which is the most grave form, death is usually expected to take place within three to
nine years after the first symptoms of the disease are noted. Very frequently pysemia sets in,
and carries of the patient with unexpected suddenness. The macular or the anaesthetic form
of the disease may develop gradually, and exist for a long time without any marked impair-
ment of the patient's health. Twenty- four years has been fixed as the extreme limit of the
disease by physicians who have had the opportunity of observing it where it is endemic.
(17»)
DISEASES OF THE SKm.— NEOPLASTIC.
RHINOSCLEROMA.
Rhinoscleroma is a rare disease which has been observed in Europe, but not, as far as I
am aware, in this country. The essential features of the disease, as the name implies, con-
sists in an induration of the nose. This induration begins in the form of flattened nodules
or circumscribed patches which are usually seated at the anterior nares. They are smooth^
of normal color or of a brownish hue and sensitive to pressure. They gradually increase in
size, and involve both the mucous membrane and the skin of the nose and a portion of the
upper lip. In time the nose becomes transformed into a hard, rigid and flattened mass of
tissue, the nasal passages being diminished in size or completely obstructed. The gro^\^h
exhibits no tendency to softening or ulceration, although fissures may form at the base of the
alse nasi, and become covered with a crust.
The cause of the disease is unknown. Its course is a chronic one and apparently inde-
pendent of any constitutional condition. The unsightly deformity which the growth pro-
duces and the impeded respiration are the only symptoms of which the patient is likely to
fiomplain.
Treatment. The disease will not yield to any treatment short of cauterization or partial
excision, and even this plan has usually been followed by a subsequent return of the growth
to its former condition.
EPITHELIOMA-
Synonym — Skin (lancer.
The term cancer implies a malignant growth which tends to invade and destroy certain
tissues (notably the cutaneous and glandular), which is prone to recur after excision, and
which induces a peculiar diathetic condition frequently ending in death. Epithelioma is one
of tlie least malignant forms of cancer, and develops primarily on a cutaneous or mucous
surface.
Like other affections of the skin, epithelioma presents a variable appearance in different
subjects, in different parts of the body and at different stages of its growth. Four clinical
forms may be described, viz. , a supei-ficial, a rodent, a deep-seated and a papillomatous form.
These forms or phases may present themselves in a single case as successive stages in the pro-
gress of the disease.
The sup«rficial form appears at first as a small, roundish, slightly elevated patch of col-
orless infiltration. It may remain in this condition for three or four years, scarcely noticed
by the patient. Slowly one or more flattened papules of a yellowish-white or waxy hue are
developed, forming a rather prominent and dense growth, usually of circular or oval .form.
Arriving at the size of a three or five-cent piece the central portion becomes depressed, while
the border lemains smooth and glossy or assumes a nodular aspect. Frequently the growth
is composed of three or four nodules grouped so as to resemble the crown of a molar toof h.
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EPITHELIOMA.
with fine blood-vessels running between them, and ramifying in the central depression.
When superficial ulceration develops a thin scab in this central pit, the growth bears some
resemblance in form and appearance to a well-developed vaccine vesicle.
The rodent form, i. e., a rodent ulcer, may begin, as has been intimated, in the center of
the superficial, button-like epithelioma, and, by extending in depth and circumference, grad-
ually convert this into a circular, polygonal or irregular ulcer with a sharp-cut border, an
elevated, indurated and flattened margin, and a clean glazed surface. By the growth of dense
waxy nodules at the periphery, and the necrosis of the inner surface of the wall, this ulcer
increases in size, and in a few years becomes as large as a silver dollar or larger. It is re-
markably slow in its growth, and may exist for fifteen or twenty years without affecting the
general health of the patient, or involving the neighboring lymphatic glands. The rodent
epithelioma often originates in an insignificant " pimple" or "wart," which becomes
scratched or injured, and forms a blackish scab. This, when removed, discovers a small
ulcer of trifling appearance, but which shows little tendency to heal. If, under treatment, it
cicatrizes, it is only to break out again and to form a larger sore. This ulcer may be annular,
and inclose an island of cicatricial tissue, or crescentic in form, or serpiginous in its charac-
ter, creeping over the surface and leaving a superficial scar in its track. The induration is so
superficial as not to be always readily distinguishable, destruction of tissue seeming to keep
pace with the new growth.
The deep-seated or infiltrating form of epithelioma may follow the superficial or rodent
form, and its clinical features will depend upon its location. When the eyelid is attacked
the disease usually begins as a superficial nodule. In a few years or sooner the whole palpe
bral opening becomes affected, and the disease assumes a rodent form. Destructive ulcera-
tion may now attack the conjunctiva and quickly destroy both lids and eye. Indeed, the
disease often progresses in depth, attacks the bones of the orbit, and produces a most fright-
ful cavity. A similar destructive process sometimes ensues when the disease is situated near
the nasal orifice or the oral commissure. When the infiltrating form begins as such, which is
usually the case upon the lower lij), there is developed a hard tumor of pea or marble size,
slightly elevated above the surface. It is at first movable, but later adheres to the subjacent
tissues. This tumor is almost invariably single, and eventually becomes an ulcer, through
t\ecrosis of the central portion of the mass and the formation of an abscess. It usually runs
a more rapid course than the rodent ulcer, and differs from this form of epithelioma chiefly
in its tendency to imi^licate adjacent glands. The papillomatous form is uncommon, and
may be regarded as a peculiar warty development of the superficial or rodent form. •
Epithelioma usually attacks the face, thirty per cent, of aU cases appearing upon the Up.
It occasionally occurs upon the genitals, particularly in the male, and may occur elsewhere.
The supei-ficial or rodent form occurs usually about the eyes and nose, while the favorite seat
of the infiltrating form is the lower lip. On the scrotum the growth is at first superficial,
but soon progresses in depth. On the glans penis, and especially the coronal portion, the
superficial or papillomatous form is most apt to occur, frequently with swelling and indura-
(181)
DISEASES OF THE SKIN— NEOPLASTIC.
tion of tlie lympliatic vessels of tlie dorsum penis. Epitlielioma usually occurs in patients
over lifty, but it may occur before that age. Seventy-five per cent, of cases occur in males.
In old persons subject to epithelioma, a peculiar atrophic whiteness of the skin over the tem-
ples is sometimes observed, \vith various indications of degeneration, such as numerous small
specks of xanthelasma and patches of seborrhoea covered by horny and blackened scales
The etiology of the disease is obscure, and in most cases neither patient nor physician can
ossio-n any reasonable cause for its development. In a small percentage of cases a family
history of cancer can be traced. Local irritation undoubtedly acts as a predisposing causes
but its influence has been overrated. For instance, the term smoKer s cancer has been used
as a synonym for epithelioma of the lip, and where a patient, as is frequently found to be
the case has for years performed Ms daily labor with pipe in mouth, the name might seem to
be warranted. But other men smoke constantly at their work and do not have epithelioma,
while the disease frequently attacks women, and men who never smoke. In like manner the
chimney-sweeper" s cancer, or epithelioma of the scrotum, occurs in countries where the con-
struction of houses is such as to furnish no occupation for this class of laborers.
TuEATiiENT. The treatment of epithelioma usually demands prompt and active meas-
m-es. When the di-sease is evidently increasing in extent by involving adjacent tissue, there
should be no temporizing. The earlier the patch can be destroyed the better, and it is as well
to destroy the healthy skin at the margin of a small patch as to allow the disease to invade
and destroy it. When progress is very rapid, the immediate removal of the diseased part,
or its complete destruction by means of a powerful caustic, is the only treatment worthy of
being considered. As to value of tonics, good food and fresh air, I need not speak as no one
will doubt their indii-ect influence in lessening the spread of the disease, and in augmenting
the beneficial effects of an operation. But while internal treatment may be advantageously
employed to put the patient in the best possible condition before attempting to remove the
growth, no time should be lost in the endeavor to eradicate it by internal medication when-
ever it evinces a disposition toward active growth. The question as to whether internal
medication can possibly have a direct effect upon the growth of epithelioma is sub jxuHce.
Although the results following the use of most of the anti- cancerous remedies which have
enjoyed a widespread though transient reputation, are either disappointing or delusive, ' t by
no means foUows that a specific remedy, or one acting as decidedly as does quinine in inter-
mittent fever, may not exist. The majority of writers agree in rejecting the idea that any
dii-ect influence can be exerted on epithelioma by the use of internal remedies. A certain
number of experienced physicians claim, on the other hand, that the disease is amenable to
internal treatment. Neligan, who describes the rodent form of epithelioma under the head
of lupus deoorans, lays stress upon the importance of administering iodine, iodide of potas-
sium and cod-liver oil in small doses continued for a length of time. He regards the employ
;nent of topical agents as auxiliary to the constitutional treatment, which he claims should
engage the chief attention of the physician. I have not such confidence in the efficacy of
these drugs, but in cases where the patient objects to the use of the knife or cautery, I -/ronld
(182)
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SARCOMA .
advise the administration of tlie remedies mentioned, or preferably arsenic, in small and long-
continued doses. Fowler's solution might be advantageously used both internally and exter-
nally, since in some cases of epithelioma with slight ulceration, healing has been observed to
follow a daily penciling of the sore with ten to twenty drops of the solution (Anderson).
In the use of caustics in epithelioma failure and even harm often results from an insuffi-
cient application of the caustic, through fear of going too deeply, or occasioning too much
pain. The growth, instead of being totally destroyed, merely becomes inflamed, and is stim-
ulated to a further increase in extent. As a rule the burning must be thoroughly done or not
at, all. The choice between the knife and caustic depends upon the extent, location and char-
acter of the growth, when there is no whim or prejudice on the part of the patient. When
the growth is large, it is usually advisable to scrape or excise as thoroughly as possible, and
to apply the deliquesced chloride of zinc to the raw surface, especially when fears are enter-
tained of a recurrence of the disease. When the growth is superficial, one or two applica
tions of a caustic paste will answer the purpose. Hebra's arsenical paste (arsenious acid, one
pai-t, red sulphuret of mercury, three parts, and cold cream, twenty-four parts), though a
painful application, acts merely upon the diseased tissue, sparing the healthy skin. It should
be applied on a piece of linen, and allowed to remain twenty-four hours, being renewed if
necessary. Marsden's paste is prepared as follows : To equal parts of arsenious acid and
powdered acacia add sufficient water to moisten and make a thick paste. This is to be spread
over the cleansed surface of the part to be destroyed, and covered with absorbent cotton. A
slough forms, dries, and falls in a week or more. As a rule, the best caustic is the one with
which the operator is most familiar. I prefer the caustic potassa, either solid or liquefied.
This forms a blackish slough, small or large, as is desired. Its action can be readily checked
by applying vinegar or dilute acetic acid. The pain resulting is not very severe, and quicklj
ceases, having this great advantage over the arsenical paste. An ointment of pyrogallic acid
(20 per cent. ) applied as a paste has recently been highly recommended.
The removal of an extensive ex)ithelioma, occurring upon the lip or elsewhere, frequentlj
involves a plastic operation to restore the lost parts. In such cases the knife is far prefera-
ble to caustics, as the removal of the disease and the restoration of the part can be combined
in one operation.
SARCOMA.
Sarcoma is a malignant growth which commonly involves the lymphatic glands primarilj-,
and only appears upon the surface of the skin as a metastatic form of the disease. In cer-
tain cases, however, it has been observed as an idiopathic cutaneous affection. In these cases
a number of small tumors varying in size from a pea to a marble, make their appearance
upon various portions of the body. They are at first discrete, of a tolerably firm consistence,
and present a smooth, raised surface. In time they become larger and flatter, and the cen-
tral portion is more or less depressed. When two or more develop in close proximity to one
another, they often manifest a tendency to coalesce.
(183)
DISEASES OF THE SKIN.— NEOPLASTIC.
As the name implies, sarcoma constitutes a fleshy tumor, and microscopic examination
Khows that it is composed of cellular tissue of an embryonic character. Various foi-ms of
sarcoma are described by pathologists, but there are three forms which are most apt to involve
the skin These are known as the round cell, the spindle cell and the melanotic sarcomata.
The round cell sarcoma is made up of small round or oval cells, usually no larger than
the white blood corpuscles. It commonly forms a soft tumor which is apt to be discolored
as the result of interstitial hemorrhage. In certain cases the cells are packed in masses sepa-
rated by a c(>nnective tissue stroma, forming the variety kno^vn as alveolar sarcoma.
The spii'.dle cell sarcoma is made up of bundles of spindle-shaped cells, which interlace
and form a 1 umor which is usually much firmer than the round cell sarcoma. It is not as
likely as the other forms to be followed by secondary tumors in the internal organs.
The melanotic sarcoma, which is the most common of these three forms, is made up of
cells which are usually spindle-shai^ed, and contain more or less brown or blackish pigment.
It always develops in the pigmented layer of the eye or skin, and is very apt to appear pri-
marily on the site of a pigmented mole. It exhibits a marked tendency to metastasis, and
numerous tumors of varying size are soon formed not only in other portions of the skin, but
also in ihn internal organs.
DiAONOsis. The diagnosis of sarcoma occurring in a multiple form is usually easy. A
solitary tumor in the absence of pigmentation and ulceration might be mistaken for a syphi-
litic gumma, but the firmness of the latter gro\vth and the history or coincident symptoms
of syphilis w ould usually reveal its nature. A single ulcerated sarcoma may be recognized
by its marked tendency to bleed upon the slightest provocation.
Tkeatjiext. a solitary sarcoma may be excised or destroyed by means of the galvano-
cautery, ample precautions having been taken to control the hemorrhage which is often ex-
cessive. Th« disease is likely to return in situ, or to manifest itself in some other part. In
multiple sarcoma curative measures are scarcely to be hoped for, and usually the fatal termi-
aation can only be delayed by treatment.
Kobner, however, has reported a case of general sarcoma cured by the subcutaneous
injection of arsenic. The patient was a girl eight and-a-half years old, who presented nu-
merous small, hard, brownish-red nodules on the face and both upper and lower extremities.
The treatment lasted a year or more, and resulted in the complete disappearance of the small
tumors, which microscopical examination had shown to be the unmistakable products of a
genuino spindle-ceUed sarcoma of the skin and subcutaneous tissue.
(184)
CHAPTER VII.
NEUROTIC DISEASES.
The part which the nerves of the skin play in the production of cutaneous disease is a
very important one. Inasmuch as the nutrition of the skin and its functional activity are
dependent upon nervous inHuence, the prime factor in the etiology of many skin affections
may be sought and found in an impaired condition of the nervous system. Many other
affections are greatly aggravated, if indeed they are not caused by irritation reflected from
internal organs, and hence it may be safely asserted that a neurotic element of greater or less
importance may be shown to exist in the majority of diseases of the skin. In some an actual
lesion of the brain or nerve trunk has been demonstrated, but the clinical appearances of
such affections have led to their association with other classes. In the present class are
included merely those cases in which there is an abnormal sensibility of the skin, with no
special lesions of an inflammatory or other character. This abnormal sensibility may be
classed as hyperaesthesia, anaesthesia or parsesthesia. Under the latter head are included two
affections in which the functional disturbance of the nerves is one of quality rather than of
quantity. These are pruritus and dermatalgia.
An extreme sensibility of the skin is not unfrequently met with in connection with gen-
eral nervous derangement, and in certain rare cases it may be met with alone, The whole
surface or but a limited portion of the skin may be affected, and the slightest external irrita-
tion may suffice to produce vasomotor disturbance with various subjective sensations. The
hyperaesthesia in one case may be readily excited by friction of clothing, whUe in others it
is more likely to be the result of heat or cold. A complete or partial loss of sensibUity of
the skin is often observed in the case of hysterical females, without any cutaneous lesions-
In a few skin diseases, and notably leprosy, anaesthesia may be a prominent feature of the
affected parts.
PRURITUS.
Pruritus, or "itching," is usually a symptom rather than a disease, but to very many
cases in which there is an intense itching of the skin, evidently of internal origin, the term
" Pruritus cutaneus " is conveniently applied. The itching, which is associated with eczema,
scabies and certain other pruriginous skin affections, is not included in the present disease,
which is whoUy independent of any structural alteration of the skin. The affection, thus
limited, is usually a chronic one and may involve the whole skin or be limited to a particular
region, such as the anus, scrotum or vulva. The sensation experienced by the patient is
(186)
DISEASES OF THE SKIN—NEUBOTIC.
variously described as prickling, crawling or burning. It is very annoying even when slight,
and in its most pronounced form is capable of destroying all sense of comfort and sometimes
driving the unfortunate sufferer to the verge of suicide. During the day the itching may be
comparatively slight and only troublesome when the patient is overheated or excited. At
night, however, severe exacerbations occur and often many sleepless hours axe devoted to
i neffectual attempts to quell the torment by constant scratching.
In the worst cases of pruritus an impairment of the general health is always noticeable.
This may be considered as partly the cause of the affection and partly the result of the in-
tense suffering which the patient is forced to undergo. Many causes of the affection have
been discovered by the careful study of cases, but nevertheless its etiology is frequently
obscure. Hepatic and renal disease frequently give rise to itching of the skin. In jaundice
it is observed in a large proportion of cases at the outset of the attack or even some time
before, and probably is due to the circulation of abnormal biliary constituents in the blood.
In diabetes an irritable condition of the skin is very common, and in many cases of Brighfs
disease it is also met with. Indeed, the connection between cutaneous pruiitus and renal
disorder is so intimate that in every case of chronic itching of the skin occurring without
apparent cause, a careful examination of the urine should be made. In this connection it
may be mentioned that severe and prolonged cutaneous irritation may be one of the causes
of albuminuria. The ingestion of certain drugs is well known to occasion itching of the
skin, and the pruritus resulting from opium is mentioned by many of the earliest medical
^^•riters. In advanced age pruritus is occasionally found to be a distressing and intractable
affection. Sudden changes of temperature often give rise to it, and the change from light to
heavy underclothing in the autumn or early winter is apt to occasion a temporary itching of
the skin in many persons.
The cause of localized pruritus is often found to reside in a venous congestion of the part.
In pruritus ani, e. g., the suffering is invariably aggravated by constipation and obstruction
of the portal circulation, whUe in pruritus vulvae, uterine engorgement and pregnancy are
well kno^\'n to be exciting causes. In children, worms are not infrequently productive of
itching, not only of the anus but of the nose.
Diagnosis. In cutaneous pruritus, as has already been stated, there are no primary
lesions. There is simply an itching of the skin with the excoriations or scratch-marks wliicli
result from the use of the finger nail? In many cases the skin presents a normal appear-
ance at the time of examination, and the diagnosis must be based upon the statement of the
patient as to the constant or frequent irritability of the sldn and the unconquerable desire to
scratch and tear it. Usually, however, we find corroborative evidence of this statement in
tlie form of hyperaemic patches which have been recently rubbed or scratched, linear excori-
ations lapon the skin or disseminated blood-crusts. In very chronic cases there may be a cer-
tain amount of pigmentation, either general or localized.
The absence of lesions, save those which result from scratching, will usually enable one
lo distinguish the affection from a number of itching eruptions with which it may be con-
(186)
PRURITUS.
founded. When the prnritus is localized it is very apt to give rise in time to eczema, the con-
stant scratching causing an inflammatory and thickened condition of the skin. In general pru-
ritus the affections likely to be mistaken for it are urticaria and the animal parasitic diseases.
Urticaria is readily recognized when wheals are present, but as these lesions have fre-
quently disappeared when the patient is seen by the physician, and only the marks of scratch-
ing are to be observed, the case is liable to be considered as pruritus. In such a case the his-
tory given by the patient of sudden outbreaks of red or white "lumps," and the character-
istic irritability manifested after the finger nail is drawn rapidly over the sldn must serve as
the basis of a diagnosis.
Scabies will often occasion itching and excoriation of the skin in cases where there are
no lesions upon the hands, and hence the parasitic origin of the affection may be overlooked.
In adult males a few inflammatory nodules or excoriations upon the genitals will point with
certainty to scabies, and in children the fact that two or more in a family are simultaneously
affected will suggest a contagious affection in place of pruritus.
Phtheiriasis occasionalb' occurs among patients whose social position would not lead one
to suspect that a few pediculi were harboring in their clothing. In such a case the itching of
the skin is often unaccountable until a most careful examination reveals the hemorrhao-ic
points produced by the " bite" of the pediculus, or brings a stray insect to light, and thus
settles the diagnosis.
Treatment. In no disease of the skin is it more necessary to consider the general con-
dition of the patient in order to effect a cure than in pruritus. While great relief will often
be obtained from the use of local ajjplications, it is evident from the host of these that have
been recommended that they only afford temporary palliation of the trouble, and that o-en-
eral treatment must be relied upon to effect a cure. Attention to the internal disorders whicli
have been already mentioned as causing or aggravating the itching of the skin is the first
step in treatment, and in some cases the only step which is necessary to be taken. When no
abnormal state of the stomach, liver or kidneys can be detected, the tone of the patient's sys-
tem should be improved by hj-gienic treatment, and in many obstinate cases, an entire chano-e
of diet, scene, etc., will not only improve the patient's health, but at the same time di\'ert
his mind from the condition of his skin until a cure is unconsciously effected.
Of internal remedies a number have been recommended as tending to allay cutaneous
hypersesthesia. Of these gelseminum and pilocarpine deserve especial mention. The value
of gelseminum, as an anti-pruritic, as suggested by Bulkley, I have found to be quite marked
in a number of cases, especially in old people. Prom ten to fifteen drops of the fresh tincture
may be given at bed time or at intervals of two or three hours, until the itching is controlled
or the chai'acteristic toxic effect of the drug is noted. Pilocarpine may be given in the form
of fluid extract, in small and repeated doses, until a slight decrease of perspiration is noted,
when the pruritus will often be found to have disappeared or abated. Hypodermic injections
of the muriate of pilocarpine have produced excellent results both in the pruritus of youth
and old age. Behrend speaks highly of the internal use of carbolic acid.
(187)
DISEASES OF TEE SKIN— NEUROTIC.
The local remedies which have been employed for the relief of itching are innumerable,
the majority of them being of much less value than one would infer from the statements
made as to their effects. At best they are simply palliative and only relieve the patient's
suffering until the cause of the itching is removed. Warm baths containing starch or carbo-
nate of soda will soften a dry, harsh skin or soothe an irritated one, and constitute one of the
most important methods of local treatment in cases of universal pruritus. After the bath
the skin may be rubbed with alcohol and anointed with some mildly stimulating unguent.
The stimulating applications which cause the skin to tingle or bum for a few minutes
are often followed by a complete relief of the itching for several hours. Of these carbolic
acid is one of the most reliable if used of sufficient strength. The following lotion may be
used at first, diluted with two or more parts of water, and then gradually increased to its
full strength, if found nescessary.
9 Carbolic Acid, .... 25 parts.
Glycerine, 25 *'
Water to 100 "
M.
Chloroform is a good local remedy and may be used in the form of the officinal liniment.
Pruritus of the anus is often relieved by the pressure of a tuft of cotton or other foreign
body iatroduced into the sphincter, when lotions and ointments have failed to give relief.
Pruritus of the vulva may likewise be relieved by introducing a tampon of cotton soaked in
glycerine and water, with a string attached for its convenient removal.
DERMATALG-IA.
Synonym — Neuralgia of the Skin.
In certain rare cases a limited portion of the skin becomes the seat of an intense pain or
burning sensation which is generally paroxysmal in character. This may exist without any
change in the appearance of the skin, although in most cases the sensation is apt to be
quicldy followed by an erythematous condition, and in some instances by the outbreak of
vesicles. The affection is always symptomatic in character and is due to some lesion of the
nen-e centres or tract leading to the affected part. In some cases it has been referred to a
nerve lesion of syphilitic origin, and in other cases has been observed in connection with
locomotor ataxia. It is most apt to occur in middle aged females, and particularly at the
period of the menopause. I have recently seen a lady suffering from locomotor ataxia whose
foot and ankle gave her intense pain, which was referred to the skin, and which was invaria-
bly followed by an erythema and indistinct herpetic eruption.
Treatment. The application of hot water may be resorted to in this affection, or the
oleate of mercury and morphia rubbed into the skin.
(188)
FAVUS CAPITIS
FAVU3 CORPORIS.
CHAPTER VIII.
PARASITIC DISEASES.
PAVUS.
Synonym — Tinea Favosa.
Favns is a parasitic disease occurring upon the scalp or on non-hairy parts, and is char-
acterized by the development of sulphur-colored cup-shaped crusts. These are not met with
at all stages of the disease, although they are generally present. At the beginning there
may be simply a circular f arfuraceous patch, which on the body cannot be distinguished
from trichophytosis or ringworm. Soon, however, bright yellow specks are seen, and as the
cup-shaped crusts rapidly develop, it will be noted on the scalp that each one is seated at the
mouth of a hair follicle, and that its centre is generally perforated by a hair. As these
" cups" become numerous they tend to coalesce, and a thick, irregular crust of lighter color
is formed, and the original cup-shaped crusts can be found only about hairs at the margin of
the large patch.
If, in any case of incipient favus, the crusts be removed and the hair shaven, the scalp
will appear smooth and m a tolerably healthy condition, and the development of the disease
may be conveniently studied. In about two weeks the parasitic growth which has remained
in the follicl<^s will show itself on the surface of the scalp in the form of minute yellow
crusts around some of the growing hairs. These crusts being covered with a layer of epider-
mis are not, strictly speaking, upon the surface. When in a few days they have reached the
size of a split pea, the margin becomes elevated and the centre depressed, forming the favus
"cup." This is concave on the upper surface and convex beneath, fitting into a correspond-
ing depression of the scalp, which is covered with a very thin layer of epidermis. The
peculiar form of the cup arises in the following manner : The spores of the parasite grow
between the layers of the epidermis, at the funnel-shaped mouth of the hair foUicle. As the
fungous mass increases in bulk, it raises the superficial layer at the periphery of the disc
above the surface of the skin, while in the centre, where the epidermis is in connection with
the hair, and immovable, a pit is consequently formed. On the under surface nothing hin-
ders the mass in its growth from pressing down upon the succulent cells of the rete, and the
convexity of the inferior surface of the cup, and the corresponding depression of the scalp
is thus produced. When a case of favus goes untreated the crusts invade a large portion of
the scalp, increase in bulk while fading in color, and finally, becoming quite friable, break
uiid tend to fall off in piecemeal. The pressure of the cups causes atrophy of the haii- roots.
(189)
DISEASES OF THE SKIN.— PARASITIC.
and bald spots of a dull, purplish-red hue, and cicatricial appearance are seen after the fall
of the crasts. The hair nevei- grows with normal luxuriance after a severe attack of favTis,
but the scalp is covered with a sparse growth of wiry and curling hairs. The disease, un-
treated, persists until the whole scalp is affected, and the hair very nearly destroyed.
The disease presents somewhat different features according to its seat. On the head,
where it usually appears, it is not often seen by the physician at the outset, but only when,
through ignorance or wilful neglect or mismanagement, it has been allowed to extend over con-
siderable ground. Favus epidermidis, or f avus corporis, as it is more appropriately termed,
is not as apt to be as severe as favus capitis. It does not present the accumulation of friable
crust, and is far more amenable to treatment, on account of the inability of the spores to
take root in deep follicles. The reddened and scaly circular patches which precede the devel-
opment of the cups, and present a notable similarity to patches of ringworm, can be well
studied in these cases. Sometimes favus co-exists upon the scalp and non-hairy parts, bxit
in a number of cases of favus corporis coming under my observation, the scalp has been free.
It has been reported as attacking the finger nails, and from the itching of the affected scalp
its transference to the nails would not appear strange.
Favus occurs chiefly in childhood, although from lack of proper treatment, it may per-
sist upon the scalp and be observed in middle life. It is i-are in this country, as compared
with its occurrence in some parts of Europe. The disease is contagious, and as it is trans-
ferred directly to another, those most Likely to contract it are children in schools and crowded
tenements. Though a local disease, it seems to flourish best upon the scalp and skin of those
who are poorly fed and cared for, and those in impaired health. Family pets aie often a
source of the disease, and in every case of its occurrence in a household, it is well to exam-
ine the dog and the cat. Mice seem peculiarly subject to favus, and are often caught with
large, yellow crusts upon their heads. Through the cat they transmit the disease to some
member of the family. In spontaneous cases, it is probable that the spores have been carried
through the air, and found a favorable nidus upon a moist scalp or patch of skin. A well-
marked case of favus of the scalp exhales a peculiar odor, which has been likened to that of
mice or of an ill-kept menagerie.
Treatmkxt. The treatment is simple, although it requires much time and patience to
cure a case in which the scalp is extensively affected. Favus of non-hairy parts can be readily
cured by softening and scraping off the crusts and applying one of the numerous parasiticide
remedies. A few weeks, at most, sufiice for a cure. Upon the scalp the spores of the para-
site have usually invaded the deepest portion of the follicles, and consequently no superficial
applications can effect a radical cure, at least, until the hairs have been pulled out. This
must be done over the whole of the affected surface, and in obstinate cases, repeated a num-
ber of times. After the epilation, a one-half per cent, lotion of corrosive sublimate, or a
three per cent, ointment of chrysophanic acid may be well rubbed into the scalp several times
a day, and continued until both scalp and hairs have apparently assumed a tendency to
healthy growth. Even now, however, it cannot be asserted that the disease is cured, with-
(190)
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FA VUS.
out a microscopical examination of some of the new hairs from different portions of the
scalp.
TRICHOPHYTOSIS.
Synonyms — Herpes Tonsurans. — Tinea Triehophytina. — Ringworm.
Trichophytosis is an affection of the sldn resulting from the growth of a microscopic
plant called the Trichophyton. It is one of the three vegetable parasitic diseases of the skin,
the other two being chromophytosis a ad favus. Like these, trichophytosis is contagious,
possessing the quality in a far more marked degree than chromophytosis. Children are more
susceptible than adults to contagion, and when once introduced into a family or school the
disease is apt to be conveyed from one to another untU nearly all are affected. It is some
times obsen^ed in horses, cows, cats and other domestic animals.
From the peculiarities presented by trichophytosis, according to its location, iive regional
forms of the disease may be conveniently described. These are given below in the order of
their importance, and with their most frequent synonyms appended.
Trichophytosis capitis. . . . Tinea tricophytina tonsurans.
" barbae. , . . Tinea sycosis. Sycosis parasitica.
" corporis. . . Tinea tricophytina circinata.
" cruris. . . . Eczema marginatum.
'* unguium. . . Onychomycosis.
On the general surface of the body (T corporis), where the eruption can be most satisfac-
torily observed, the disease begins either in the form of a group of minute vesicles, or a small,
reddened, scaly macule, which, increasing in size, presents a circular outline and a slightly
elevated margin. The skin is but slightly inflamed as a rule, and at the advancing border of
a typical patch a circle of minute vesicles may be sometimes discovered upon close examina-
tion. The patch extends at the periphery, and as the elevated margin creeps over the healthy
skin, the central portion becomes but slightly, if at all elevated, and far less scaly than the
border. In many cases the enclosed area becomes quite normal or remains somewhat pig-
mented, and the eruption presents a characteristic annular appearance. There is rarely but
a single focus of disease, and in many instances a score or more of circular patches may be
counted. When these are near each other they coalesce as they increase in size, and large
patches of irregular outline result.
Trichophytosis of non-hairy parts (T. corporis) occurs in both sexes, and at almost all
ages. It has been reported as occurring upon an infant six hours old.
In the genito-crural region (T. cruris) the parasite grows luxuriantly, owing to the heat
and frequent moisture of the parts affected, and the eruption extends upon the buttocks and
inner surface of the thighs. It produces in this region an unusual amount of dermatitis, and
in many subjects a pronounced eczema. In the tropics this form of disease is common and
obstinate.
(191)
DISEASES OF TEE SKIN:— PARASITIC.
On the scalp (T. capitis) or bearded portion of the face (T. barbae) the disease begins in
the form of one or several small, scaly patches. After having existed a short time without
treatment, the hairs springing from the patch lose their lustre, become brittle, and finally
break off very near the surface of the skin. The patch, which has now perhaps reached the
size of a cent or quarter dollar, appears bald at first glance, but on close inspection is found
to be covered with white powdery scales, through which the broken hairs project like stubble.
Trychophytosis capitis is never seen in adults, although the occurrence of the disease upon,
the bearded portion of the face is by no means uncommon. Trichophytosis of the beard
may be contracted in the barber's chair, and constitute one form of the so-called " barber's
itch," which term is usually made to include eczema and sycosis. It does not arise from the
use of an unclean razor, as is commonly imagined, but from the use of a damp, soiled towel,
which furnishes a most excellent nidus for the growth of any vegetable parasite.
In certain cases of ringworm of the scalp or beard a marked inflammatory reaction is
occasioned by the penetration of the spores into the deeper portion of the hair follicles. A
peculiar condition of the skin is produced, which differs greatly in appearance from the ordi-
narj' form of the disease. It is commonly knoAvn as kerion, or the kerionic form of ringwonn.
It usually begins with the developinent of one or several small, pea-sized tumors, which are
always reddened and "boggy," and which often present a deceptive feeling of fluctuation
which is apt to lead one to declare them abscesses. In spite of the appearance presented bj^
these little tumors, it is a noteworty fact that they rarely if ever suppurate. The fluid con-
tained in the deeper portion of the corium, and which gives to the swollen part its soft,
spongy feeling, is a highly albuminous serum, which appears in the form of viscid, honey-
like drops, at the dilated orifices of the follicles, especially after the hairs have loosened and
fallen. This loss of hair, which usually takes place soon after the affection has developed,
is limited to the portion of the scalp affected. The little tumor remains for an indefinite
period of a livid red hue, and then tends to gradually fade and flatten, unless similar lesion*
develop in the immediate vicinity. Sometimes, especially in young children, it enlarges
peripherally, and forms a soft, flattened, and but slightly elevated disk, as large as a half
dollar. Generally, a group of closely packed tumors, or mounds, develop, and the symp-
toms already described as pertaining to a single small tumor present themselves in an exag-
gerated form.
Trichophytosis affecting the nails (T. vvguium) is extremely rare, but it maj' occur
either alone or in connection with rings of the disease tipon the hands or other portions of
the body. The nails, one or more of which may be affected, become thickened, discolored,
and friable. Those of the fingers are more likely to suffer than those of the toes.
Diagnosis. The diagnosis of trichophytosis is often so simple that it can be made by
the patient. When the eruption, however, has been treated and partially cured, or when, on
the other hand, it has been maltreated or overtreated, so that it has become obscured by a
secondary eczema, the physician must be cautious in venturing an opinion until a microscopic
examination has determined the presence or absence of the parasite. The diseases with
(192)
TRIG HO PR TTOSIS.
A-. liicli it is most likely to be confounded are favus, psoriasis and eczema. In tlie early stage
of favus, before the characteristic yellow crusts have developed, the appearance presented is
very similar to ringworm, and a diagnosis can only be based on a microscopic examination of
the hairs. Psoriasis sometimes appears in the form of circular, reddened patches, mth a
very moderate amount of scaling, closely resembling the patches of trichophytosis, and
wlien on the wane they tend moreover to heal in the center, and form rings which have often
been mistaken for ringworm by physician as well as patient. The peculiar location and sym-
metry of the eruption in psoriasis will generally serve as a guide in diagnosis.
Eczema may simulate every skin disease. In its dry and scaly stage, especially when
occurring as one or more small roundish patches, such as may be met with on the face, breast
or hands, it resembles trichophytosis in being hyperaemic, scaly and itchy in a moderate
degree. The patch of eczema, however, is rarely circular, and generally shades off into the
surrounding skin instead of presenting an abrupt margin. Furthermore, there is never any
tendency toward healing in the central portion of the patch. Trichophytosis capitis is often
confounded with eczema, bi^tthe circular form of the patch, the absence of moisture, and par-
ticularly the mealy epidermis and the short, broken hairs ought to reveal the nature of the
affection in most cases. In all doubtful cases of skin disease, where trichophytosis or one of
the other parasitic diseases is suspected, microscopical examination of a few scales or hairs
must be resorted to in order to settle the question. The diagnosis of a weU-marked case of
kerion is attended vsdth no difficulty. The bald and lumpy condition of the scalp is not seen
in any other affection. In the earlier stage of kerion a mistake might readily occur. Where
there are a number of scattered red and soft tubercles upon the scalp they might be mistaken
for boils, abscesses or for syphilis. The latter disease would not be likely to occur at the age
when the kerion is commonly met with, unless it were hereditary, in which case it would not
manifest itself in the fonn of tubercles limited to the scalp. Boils would be recognized by
their more conical form, indurated base, and tendency to suppuration, while a number of
small equal-sized abscesses would not be apt to occur upon the scalp without apparent
cause. After tlie hair has faUen from the little tumors, and the boggy feeling lessened, they
might be regarded as indications of incipient alopecia areata ; but in this affection the bald
patches show no signs whatever of past or present inflammation, the affected scalp being '
white, smooth, and not at all elevated. "Where a portion of scalp is suddenly attacked, and a
copious discharge of gummy serum takes place, the affection bears a resemblance to an acute
eczema. It will be noted, however, that the hairs are loosened and pull easily, which is never
the case in eczema of the scalp.
Treatment. As trichophytosis is essentially a dermatitis of greater or less severity,
resulting from the growth of a parasitic fungus in or tipon the skin, its treatment must con-
sist mainly in the use of local measures. As the trichophyton will take root and thrive upon
a perfectly healthy skin, it is evident that internal treatment cannot effect a cure. At the
same time clinical observation teaches that in certain conditions of the system the skin affords
a more favorable soil for the development of the fungus. The affection appears to be more
(193)
DISEASES OF THE SKm.— PARASITIC.
disposed to spread, and to be less easily checked by the action of parasiticides, when the
patient is ill-nourished or physically depraved. Internal roni^dies may, therefore, in a slight
deo-ree at least, prove conducive to a cure, and in a majority of cases it is advisable to look
well after the general health while carrying out the local treatment. Cod-liver oil, by pro-
moting nutrition of the skin, and bathing, by rousing into activity the cutaneous functions,
produce a beneficial effect, and are especially called for by the class of patients affected, many
of whom are of a lymphatic temperament, averse to fatty food, and with a dull, torpid, pasty
skin.
The main object of local treatment should be, (1) to reduce any undue amount of inflam-
mation, shoidd such be present, and (2), to destroy the very last germ of the parasite. Suc-
cess depends upon the appropriateness of the remedy. Failure may result from the use of
one which is too weak, or from the too long continued use of one which is unnecessarily
strono-. In most cases vigorous local treatment may be instituted at once, but on the soft skin
of childhood, and on certain regions in the adult where the skin is thin and easily inflamed,
it is preferable to employ the milder parasiticide remedies for a greater length of time, than
to risk the production of a severe dermatitis or eczema. To destroy the parasite it is usually
necessary to destroy the epidermis and hairs which are invaded. Where the disease occurs
on non -hairy parts, it is commonly superficial and easUy cured. As the spores and mycelium
grow between the cells of the horny layer of the epidermis it is evident that whatever will
remove this layer wUl carry away with it the j)arasitic growth. When this, however, has
grown down into the hair follicles, and even penetrated the hairs themselves, the disease is
not readily cured. It maj' indeed prove exceedingly intractable, and recur after it is appa-
rently well.
The treatment of kerion consists in improving the general tone of the patient, and in
thoroughly epilating the affected part. Whether the disease is of parasitic origin or not,
epilation is demanded by the condition of the hairs, which are not broken off, but lie, as in
case of sycosis, lilie foreign bodies in the inflamed follicles. Their extraction removes a
source of irritation, and the free discharge of viscid serum through the follicles lessens the
boggy condition of the scalp and promotes the subsidence of inflammation. It must not be
exjiected that epilation will effect a speedy cure of the affection, even when the trichophytic
fungus is present as an exciting cause. As the fungus, in this case, is not the sole cause of
the peculiar phlegmonous condition, its removal with the hairs will not produce as striking
an improvement as in cases of ordinary trichophytosis capitis.
On the general surface of the body, where the hairs are fine or absent, the disease can be
removed mechanically by scrubbing the affected part daily with sapo viridis. This alone will
usually suffice, but the patient is apt to be more contented, and indeed, the cure may be
hastened, if he applies an ointment or a lotion to the affected part between the soap frictions.
An ointment of thymol (three to five per cent.), or of carbolic acid (ten to fifteen per cent.\
or a lotion of the hyposulphite of sodium (twenty per cent.), will be found very useful.
These remedies have the power to arrest the development of vegetable spores, if not to
(194)
^'»rtn^r-"iLaiiila«i-
TRICHOPHYTOSIS. MANUS.
TRICHOPHYTOSIS CRURIS-
ARTOTYPE, E. SlCRSTAOT, N.
TRICIIOPII YTOSIS.
atterlj- destoy them, but to secui-e their beneficial action they must be applied with great
frequency, as the parasitic spores multiply with amazing rapidity, and no time should be lost
between the applications. Most of the so-called parasiticides, however, merely have an
astringent or slight caustic action, and would be more properly termed epiderrnicides. Com-
mon ink, and a copper cent dipped in vinegar, are valued remedies among the laity, and not
wholly without effect ; but the physician will do better to paint the patches with acetic acid
or the tincture of iodine. The latter is objectionable when the affection is on the face or
hands, o\ving to the staining of the skin. If decolorized, the tincture loses much of its effi-
cacy. A still better application is a five per cent, ointment of chrysophanic acid, or one of
the remedies already spoken of as acting in a truly parasiticidal manner. Blistering a patch
with cantharidal collodion, or some other epispastic, is a most efficacious plan of removing
the disease, but is rarely called for.
In the genito-crural form of the disease the parasitic growth is rather difficult to get rid
of, as strong applications must be used with caution. But the chief difficulty in treating
this form arises from the fact that it is so frequently associated with an erythematous eczema.
The skin is reddened, thickened and itchy, and even when the parasite has been destroyed
by the use of pure sulphurous acid, or the remedies already suggested, the outline of the
patches and their general appearance remain pretty much the same. In other words, the
eczema still remains to be treated.
The treatment of trichophytosis capitis is similar to the treatment of favus, after the
crusts have been removed, and consists mainly in epilation. In trichophytosis the hairs are
more difficult to extract than in favus, since, owing to the penetration of spores into the
fibrous portion of the shaft, the hairs break, and a patch has to be epilated repeatedly before
the scalp is left smooth and clean. The prognosis of this affection is much better than in
favus of equal extent, since the hair bulbs are not so apt to be destroyed, and consequently
the bald, depressed spots and the sparse, wiry hair, which usually result from a severe attack
of favus, do not follow. After trichophytosis of the greater portion of the scalp, the hair
may in time grow as thick and strong as ever.
Epilation may be performed in various ways. I have made some use of an epilating
paste, composed of resin, wax and balsam of tolu, molded into the form of a convenient
stick, about an inch in diameter. One end of this being melted by heat and pressed upon
the patch, a sudden twist and jerk will extract a large number of hairs at once ; but the
epilating forceps are almost universally used for this purpose. They should be carefully
made, with broad, accurately-closing and slightly-roughened blades. If too stiff they are
certain to tire the fingers of the operator where a patch of any size is to be epilated. When
the scalp or beard is recently affected, the patches small, and the. hairs normal, epilation is
not necessary. The patches may be shaved, and parasiticide applications vigorously applied
for a considerable length of time. If, now, the microscope shows no indications of a parasitic
disease after repeated examination of thehaii-sand epidermic scales, the shaving may be discon-
tinued, but the patches must be closely watched for a mouth or two, lest the disease reappear.
(195)
DISEASES OF TEE SKIN:— PARASITIC.
CHROMOPHYTOSIS.
Synonyms — Pityriasis Versicolor. — Tinea Versicolor. — Chloasma, — Hver 8pot$.
Ckromopliytosis is another of the three important affections of the skin which owe
their origin to the growth of a vegetable parasite or fungus. It is contagious, though not in
a marked degree, and patients seldom have any idea of the manner in which they contracted
the affection. The trunk and upper extremities are its favorite and almost its sole seat. It
sometimes extends upon the neck, and even upon the cheeks, and may be found, in rare
instances, upon the thighs. It usually commences upon the upper portion of the breast, and
in many cases is quite symmetrical in its development. Although, at the beginning, the
eruption may be one-sided in respect to situation, in nearly all cases of long standing, where
the whole trunk is more or less affected, the symmetrical disti-ibution of the eruption is a
marked feature.
The affection begins in the form of a few pin-head-sized, yellowish, scaly spots, which grad-
ually increase in size and number. When first noticed by the patient, there may be a score or
more of isolated, brownish-yellow, pea-sized circular patches, showing very distinctly upon
the background of the normal skin, or there may be a small irregular patch of the same
color, variable in size, with a few isolated circular spots scattered near its margin. As the
eruption increases in extent, it spreads over the upper portion of the chest and follows down
the median line as a rule towards the pubis. The back likewise becomes affected, though not
generally in so marked a degree as the breast. The sternal region, though often the first to
present the eruption, frequently becomes free in an advanced stage. The groins are usually
exempt, and the axillae and sides of the chest are not as thickly covered as the breast and
back.
The circular discs are usually slightly elevated, but the diffused patches are less so, and
sometimes can with difficulty be distinguished from normal skin. The margin may be quite
abrupt, or it may shade off so imperceptibly that it is difficult to say exactly where the
affected skin begins.
Itching is present in a moderate degree in some cases, but generally there is nothing to
attract the patient's attention to the trouble, and in patients who bathe Little, the affection
may exist for a long time, and then be accidentally discovered. Though occurring often
among those who pay due attention to personal cleanliness, and hence met with in private
practice, it is far more common in that class of i^ersons who perspire freely and bathe sel-
dom. In dispensary practice patients rarely apply for treatment, unless a guilty conscience
leads them to mistake the eruption for a manifestation of syphilis ; and yet, where patients
with syphilis and other affections are stripped for examination, chromophytosis in greater or
less extent is very frequently observed.
The disease may exist for the greater portion of a lifetime if nothing be done to remove
it. In some cases a small patch or number of patches show no tendency whatever to spread,
(19G)
^i'^!^'--' --^ -^ ^
CO
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O
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X
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O
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u
CHROMOPHYTOSIS.
v> liile in other cases portions of the body become quickly covered, and the eruption shows a
marked tendency to retnm after treatment. The disease is only met with in adults, and
occurs with nearly equal frequency in either sex. It is common in early adult life, and
rarely if ever seen upon the aged.
Diagnosis. The affection is generally recognized with ease by the color, the peculiar
configuration of the patches, and the scaling of the epidermis when scratched lightly -nith
the finger naU. In cases where the patient has bathed and nsed soap freely, the disease may
be extensive, and yet be only recognized by the yellowish or tawny hue which it imparts to
the skin. In case of doubt, the microscope will settle the question at once.
Treatment. As the disease is a strictly local one, local measures will effect a cure.
Care must be taken, however, that the treatment is faithfully carried out by the patient, else
the disease Avill only be apparently cured, and in a short time will reappear. Two points
should always be borne in mind. Firstly, that the affection is confined to the epidermis, and
whatever means wiU remove the outer layers of epidermic cells will necessarily remove the
disease. Secondly, that it Is useless -to cure nine-tenths of the disease, for if a single spot be
left, or even if the same underclothing be worn again, without being thoroughly cleaned, tlie
eruption is almost certain to return.
Soap will cure a great many cases, if the skin be scrubbed, rather than rubbed with it,
or if it be rubbed into the affected patches daily, and allowed to remain for a week. A bath
taken then will remove considerable dead epidermis, and with it the spores and mycelium of
the parasite. Common soft soap may be used when the sapo viridis, or green soap, is not
easily obtained. The following ointment or paste I have used in many cases, and always with
the most satisfactory results.
51 Green Soap, 60 parta
Washed Sulphur, - - - - 40 "
Glycerine, 10 "
M.
The tincture of iodine, painted over the patches, and daubed on the small circular spots,
wiU cause the epidermis to peel off, and thus remove the disease. This remedy, even diluted,
changes the color of the affected patches to a much darker brown than the noi-mal skin, and
hence is of advantage in revealing the presence of minute spots which might readily be over-
looked. An ointment of chrysophanic acid quickly cures the affection, but is objectionable
on account of its tendency to inflame the skin, and to stain the clothing. When the patient
is apparently free from the eruption, it is well to apply for several weeks a lotion of carbolic
Jfccid of five per cent, strength, or the following more agreeable preparation :
^ Hyposulphate of Sodium, - - 10 parts.
Rose Water to .... 100 "
M.
(197)
DISEASES OF THE SKIN.—PAEASITIC.
SCABIES.
Synonym — The ItcK
Scabies Is an affection of the skin, resulting primarily from the burrowing of minute
insects called "acari." The presence of these parasites in the skin occasions a severe pruri-
tus, and provokes a characteristic eruption, which cannot be duly appreciated and rationally
treated without a certain knowledge of their anatomical striactnre and peculiar habits
The Acarus Scabiei, or itch-mite, is a minute and almost microscopic insect. It can be
readily seen with the naked eye when extracted from its burrow or cuniculus by means of a
needle, but its features can only be studied beneath the microscope. The mature acarus is of
oval shape, and provided with eight legs. The male is smaller than the female, does not
burrow as does the latter, and is not readily found. The young acari jDossess but six legs
(two posteriorly), and these are in time thrown off with its skin, when the mature eight-leg
ged insect appears. If a female, she becomes speedily impregnated by the male, who roams
at night upon the free surface of the skin. She then proceeds to burrow, and deposit her
ova to the number of a dozen or more beneath the epidermis. At the end of this burrow she
dies, unless prematurely removed by the finger nail of her imwilling host. The ova are
hatched within fourteen days, and find their way to the surface of the skin. Here the
maiden acari are wooed, become impi'egnated, and the burrowing and hatching process is
repeated. The burrows are generally found where the skin is thin and warm, as between the
fingers, upon the penis in the male, and the nipple in the female. They appear as dotted,
slightly elevated and curving lines. Vesicles and pustules are frequently observed in their
vicinity, but the extensive eruption which, in some severe cases, covers the bodj^ and extremi-
ties, is not a direct effect of the burrowing of the acari, but results from the free use of the
finger-nails. The itching is almost intolerable, especially in the night, when the patient is
warm in bed.
The eruption in scabies is localized in great measure according to the character of the
patient's clothing, and differs in this respect in men, women and children. Upon the hands
and wrists it is common in all, but its prevalence about the breasts of women, and upon the
genitals in men and boys seems to depend upon the ease with which they can scratch in those
localities, especially at night. In young children, who wear long, close-fitting night-dresses,
the anldes, which alone are exposed, are usually the seat of an eruption. The face and scalp
are usually free from eruption, even in the most severe cases of scabies. A secondary eczema,
however, may be found upon the head, as well as on the body. The disease is usually con-
tracted at night, from some affected bedfellow. The physician may handle the hands of a
patient with impunity, according to my experience. Nevertheless, one writer has stated
that he contracted the disease " from incautiously handling and hunting for the mite on a
child's arm."
Diagnosis. The diagnosis of scabies may be based upon the discovery of burrows, or,
(198)
SCABIES
roType, e. bierstaot
SCABIES.
in the event of not finding them, upon the characteristic locality of the excoriated papulea
which constitute the eruption. The burrows are more apt to be found in mild and recent
cases than in severe cases, where the hands are covered with vesicles and pustules. When
the occupation of the patient causes the hands to be kept very much in water, they may ap-
pear perfectly free from the disease, and yet a characteristic eruption exist on the body.
Treatment. The treatment of scabies depends upon the age of the patient, the chro-
nicity of the disease, and the presence of a secondary eczema. In infants, whose tender skin
would certainly become inflamed from use of the ordinary stimulating sulphur ointment,
squal parts of vaseline and balsam of Peru may be employed with a satisfactory result. In
children and adults stronger applications may be made, although it must be remembered
that some skins can bear what others cannot. Styrax balsam, in the form of a liniment,
made by adding twenty per cent, of olive oil, or as an ointment, made from an equal part of
cosmoline, is an agreeable and effective application. Sulphur, however, has long been the
chief remedy in scabies, and although others may be equally good, there seems to be none
more efiicacious in the majority of cases. It is frequently combined \vith carbonate of potas-
sium, mercury, tar, chalk, etc., but as far as my experience goes, these compound ointments
possess no marked advantage over a simple sulphur ointment, which, if applied in strength
suitable to the case and to the various parts of the body, vnl\ leave nothing to be desired.
The Ungt. Sulphuris (U. S. P.) consisting of thirty parts of sulphur to seventy parts of lard,
is rather stronger thai^is necessary, especially when its application is to be repeated, and com-
bined with baths and soap frictions. A twenty, or even a ten per cent, ointment is prefera-
ble m most cases, for the patient generally prefers to be cured pleasantly and permanently,
to being cured quicldy. A ten per cent, ointment of naphthol is also an efficient remedy.
In a recent case of scabies, smearing the hands at night with the ointment may suffice to
effect a cure ; but when the disease is of long standing, the whole body with the exception of
the head, should be anointed. Before going to bed, the patient may remain for a quarter
of an hour in a warm bath. This macerates the epidermis upon the hands and other affected
parts to such a degree that a brisk friction with soap will doubtless exhume some of the
acari, and certainly increase the effect of the ointment which is to be subsequently applied.
Hebra warns against the injudicious use of warm baths, but the effect of bathing, in predis-
posing of the skin to eczematous inflammation is only noticed when one employs the very
strong applications which he recommends. If the eruption is seated on a delicate skin, and
especially if an eczematous tendency manifests itself, baths may be discarded, while the oint-
ment is used with great care, and not continued but for a few days at a time.
Disinfection of the clothing is unnecessary in most cases, if not in all. It is important,
however, to treat not only the patient who applies for treatment, but also the bed-fellows,
playmates or associates who may be similarly affected. Otherwise the disease will be re-con-
tracted as soon as it is fairly cured.
The duration of the treatment must necessarily vary. Ordinary cases can be cured in
from live to ten days. It is always difficult to say just when the patient is curtd, and when,
(199)
DISEASES OF THE SKFN.—PARASITIC.
therefore, the treatment should cease. Too often the treatment is continued on account of
an eruption which is not due to the acari, but to the irritating applications which are being
employed.
PHTHEIRIASIS.
Synonyms — Pediculosis. — Lousiness.
Phtheiriasis is a term which includes both the presence of lice and the cutaneous lesions
to which their presence gives rise. In some cases, where an eczematous tendency on the
part of the patient exists, the external irritation and consequent scratching is sufficient to
occasion patches of typical eczema. The older writers regarded the affection in the light of
a specific dyscrasia, of which the pediculi were a natural result, and among the laity at the
present time it is a common belief that the lice come out of the skin, where they are sup-
posed to be bred by the disease.
Pediculi are insects belonging to the group of hemiptera. They are without wings,
possess a sucldng mouth, and undergo no metamorphosis. There are three members of the
family which are parasites of the human body, viz., the pediculus capitis or head-louse, the
pediculus corporis or body-louse and the pediculus pubis or crab-louse. These occasion the
three affections known as Phtheiriasis capitis, Phtheu-iasis corporis and Phtheiriasis pubis.
The pediculus capitis is of a whitish color, and varies in size from one to three millime-
tres in length. Attached to its thorax are six hairy, jointed and clawed legs, with which
it is enabled to travel rapidly along and among the hairs. It is only met with upon the
scalp. The lice deposit their ova either singly or in groups upon the hairs. These ova
or "nits" are found, upon close examination, to be whitish, pyriform bodies, glued to the
hairs with the smaller end close to the shaft and pointing toward the scalp. They are
always deposited near the root of the hair, and accordingly, when observed near the free
extremity, it is an indication that the affection has existed for a considerable length of time.
The pediculus corporis bears a strong resemblance to the pediculus capitis, although it is
somewhat larger. Its habits are quite peculiar. It does not burrow in the skin like the acarus
or itch-mite, nor is it ever found in the hair like the other species of pediculi. It inhabits
the clothing and merely pastures upon the skin. It does not bite, but sucks the blood of its
victim through a haustellum or proboscis which it inserts into the skin. Its appetite is vora-
cious, and when observed beneath a watch-glass, during meal-time, its bodj'^ may be seen to
increase in size and assume a darker or reddish color. When numerous the pediculi may be
seen traveling over the free surface of the patient's apparel, but when a strict search is neces-
sary to discover them, they will generally be found secreted in the folds and seams of the
garments. In cheap lodging-houses, police stations and wherever lousy persons are in the
various habit of sleeping, the bed-ticks and woolen blankets may become infested.
'ITie pediculus pubis is a smaller, broad-bodied louse, which may infest any harry part
»ixcept the scalp. As the name implies, it is commonly met with in the pubic region, but
occasionally it is found in the axilla, upon the sternum, in the beard, and upon the eyelashes.
(200)
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PHTHEIRIASIS.
PHTHEIRIASIS CAPITIS.
Phtheiriasis capitis is an extremely common affection among the lower classes. Thougn
most frequently attacking children, and especially those who associate with a number of
others in schools, asylums and similar institutions, it is not infrequent among adults. Filth
and neglect act as predisposing causes, but at the same time, children who have every possi-
ble attention paid them are often affected, and even ladies of wealth and refinement sometimes
discover that they have been unconsciously harboring a large number of unwelcome and dis-
gusting vermin. Men, on account of their short hair, are much less likely to be attacked.
It is a notable fact that certain individuals are peculiarly liable to become affected whenever
exposed, and, in case of some children whose heads are carefully washed and cared for, it is
a puzzling matter to account for the repeated presence of the insects in the hair.
The first symptom produced by the presence of the pediculi is an unpleasant itching of
the scalp. In children, the continued scratching produces excoriations, and a serous or sero-
purulent discharge soon appears, which tends to mat the hairs. An eczema, especially upon
the occipital region, is frequently evoked, and this is so characteristic that, when limited to
this region, it should always lead to a search for pediculi as its probable cause. An eruption
of contagious pustules, as in the case illustrated, may appear upon the neck and shoulders.
In strumous children the irritation of the scalp may lead to a marked swelling of the Ij'm-
phatic glands of the neck.
Diagnosis. The diagnosis of the affection is readily made if the pediculi are found, but
the presence of nits upon the hairs is alone sufficient to establish it, since they indicate that
there have been, and probably will be, pediculi in the hair, even though none may have been
discovered by a careful investigation.
"When eczema of the scalp exists the presence of pediculi is often overlooked, and the
affection may be unsuccessfully treated until its parasitic origin is discovered. As above
stated, occipital eczema is an almost certain sign of phtheiriasis.
Treatment. The treatment vai'ies with the extent of the affection and the social condi-
tion of the patient. In dispensary practice it is usually advisable to have the child' s hair
cut close, especially in warm weather. If no eczema is present the lice and nits may be de-
stroyed by rubbing the scalp night and morning with ordinary kerosene. Caution should be
given respecting the danger of setting the child's head on fire by rubbing in the oil in too
close proximity to a gas-jet or candle. When severe eczema is present this must be treated
by means of a soothing ointment, although it is sometimes advisable to destroy the parasitic
cause of the eczema at the outset, even though the treatment should aggravate the eczema-
tons condition. In private practice it is not necessary to have the hair cut, and, with proper
attention, it will be found easy to cure the affection by careful combing and the nightly
inunction of the ammoniated mercury ointment. The nits are sometimes difficult to remove,
but this may be accomplished by rubbing each affected hair from root to tip with a sponge or
soft cloth dipped in alcohol or cologne-water.
(201)
DISEASES OF THE SKIN.— PARASITIC.
PHTHEIRIASIS CORPORIS.
Phtheiriasis corporis implies the presence of lice in the clothing, together with the exist-
tence, to a greater or less degree, of certain cutaneous lesions. The affection is common, and
often a chronic one among the poor and miserable, and under certain circumstances, the pos-
sessor of wealth and refinement is not protected against an acute attack. As Professor Hebra
once remarked to his students, it is not always a disgrace to have lice, but it is a disgrace not
to get rid of them speedily.
The lesions constituting the eruption in phtheiriasis corporis are : (1) peculiar hemon-ha
gic specks or so-caUed "bites," (2) small wheals or inflammatorj^ papules, (3) excoriations
either presenting a raw surface, or covered mth a crust of dried blood, (4) scratch marks ol
parallel direction, such as are not met with upon the skin, except as a i-esult of phtheiriasic
irritation, and (5) pustules, furuncles and supei-ficial ulcerations.
The eruption is observed chiefly upon the body and thighs. It is always most marked
in certain localities which correspond to the seams and folds of the clothing, where the pedi-
culi secrete themselves, and deposit, in great numbers, their small, white and shining eggs.
A tract of skin that can be' almost covered by the palm, lying between the upper portion of
the scapulae, is a spot most likely to present excoriations, since it is a favorite habitat of the
lice, and quite accessible to the hands of the patient. The eruption in this locality usually
presents a striking appearance, the skin being frequently pigmented, and showing old cica-
trices scattered among the recent excoriations. The eruption is also apt to be well marked
around the loins, presenting a distribution which might be termed the phtheiriasic girdle.
This is commonly observed when the trousers are supported by a belt. Excoriations are
common about the trochanteric region and outer aspect of the thighs, when the trousers are
chiefly infested. I have seen a patient with dark stripes running down the thighs and legs,
and corresponding to the seams, which were swarming with pediculi and their ova.
Diagnosis. The diagnosis of phtheiriasis corporis can usually be made by observing
the patient at a respectful distance — a very fortunate circumstance for the physician, who in
charity practice has to treat a large number of cases. When the patient strips, the nature o/
the affection, if it be of long standing and weU-marked, is evident from the characteristic loca
tion of the scratch marks, and from the fact that the patient finds it impossible to keep hi?
bands stUl. There is no other disease in which the pruritus is so intense as in a severe case
of phtheiriasis. Exposure of the body to the cool air seems to excite the desire to scratch.
If the patient is requested to stand perfectly still, with his hands hanging, he may retain his
soldier-like position for a few seconds, when he wiU probably begin, with both hands, to rub
and scratch, and even to tear the skin, until it is bleeding at numerous points. The pruritic
character of the eruption being thus manifest, we are led at once to exclude a diagnosis of
syphiloderma and every other non-pruritic skin affection, and to think of urticaria, prurigo,
eczema, or scabies, eruptions which are always accompanied by severe itching. The irrita-
bility of the skin, shown by the parallel pink streaks which follow in the wake of the finger-
(202)
FBTHEIRIASIS.
nails, and tjie rapidly developing white ridges or small wheals, is a striking feature of urti
caria, and might lead to the diagnosis of this affection. But in urticaria the severe excoria
tions are lacking, and the eruption is usually of recent and sudden development. Prurigo
in the severe form, which is seen in the skin clinic of Vienna, is rarely, if e^er, met with in
this country. In a mild form it is occasionally encountered, and can be distinguished from
phtheiriasis by its attacking chiefly the extremities, and being invariably a disease of long
standing.
A case of phtheiriasis might be diagnosed as one of papular or pustular eczema, the dif-
ference in the appearance of these eruptions not always being very marked ; but the charac-
teristic location of excoriations across the back of the shoulders, around the waist, and upon
the outer surface of the hips and thighs, should point at once to their parasitic origin. Sca-
bies, when affecting the body extensively, may resemble phtheiriasis, but it manifests a
strong preference for the hands, forearms, lower part of abdomen, genitals, and the inner
aspect of the thighs, while avoiding the favorite seats of phtheiriasic lesions. It is intensely
pruritic, as the common name of "the itch" suggests, but the patient scratches with com-
parative gentleness, and never digs the skrn with fury, as in case of phtheiriasis.
It will thus be seen that the diagnosis is easy, in a severe form of the affection, but fre-
quently cases occur in which only a moderate pruritus, with very few excoriations, is present.
Here it may be impossible to discover any pediculi, and it is sometimes extremely difficult to
distinguish the affection from the pruritus cutaneus, which is a neurotic affection, depend-
ing upon some internal disorder. The hemorrhagic points produced by the haustellum of
the pediculus can generally be discovered, however, and serve an excellent purpose in point-
ing out the parasitic origin of the trouble. When in private practice there exists a suspicion
of pediculi (and phtheiriasis is not wholly confined to dispensary patients), it is far prefera-
ble to quietly hunt for these characteristic lesions of the disease, than to give offense to a
patient by instituting a fruitless search through the clothing.
Treatment. The treatment of phtheiriasis corporis consists in getting rid of the pedi-
culi, and soothing the irritation of the skin, which their attacks have occasioned. In dispen-
sary practice, I might say that the first aim of treatment should be to convince the patient
that the eruption is not due to " heat " or "humor" in the blood, but that it is the natural
result of lice in his clothing. The patient may be ignoi-ant of the existence of lice, (though
generally is conscious of their presence), but yet so thoroughly possessed with the idea
that they are the effect, rather than the cause, of the eruption, that it is vain to argue the
point, and hopeless to give directions for treatment. Such cases can only be treated satisfac-
torily in hospitals, where enforced cleanliness is possible. When the patient appreciates the
fact that the lice cause the eruption, he may be directed to change his clothing throughout,
with a fair prospect of his doing so. It is not sufficient, as many patients imagine, to put on
a clean shirt once or twice a week, or even oftener. The patient must be told and shown, if
necessary, that the outer garments are infested, and that it is essential to change these as well
as the underclothes. AVhile the latter are being boiled, the former may be baked in a hot
(203)
DISEASES OF THE SKm.— PARASITIC.
o: en, with the probable result of destrojdng both lice and ova. It may not be superfluous,
he wever, after the clothes have been thoroughly baked, to sprinkle the seams, where the ova
were numerous, with sulphur, pyrethrum or staphisagria. As regards the eruption on the
body, this will quickly disappear when its cause is removed. A daily warm bath ^vill prove
agreeable and beneficial when the skin is greatly irritated. For dispensary patients I usually
prescribe an ointment or lotion of carbolic acid, which tends to allay the itching, and to
repel the parasite.
PHTHEIRIASIS PUBIS.
Phtheiriasis ^m5i« is a pruriginous affection of the hairy region to which "crab-lice"
have gained access. The mons pubis is the part usually affected, as the lice are apt to be
transferred from one individual to another during sexual intercourse. Their presence occa-
sions a considerable amount of itching and the frequent scratching of the affected part soon
gives rise to an eruption of small papules, and in some cases to an eczematous condition.
The lice are not readily discovered, if unsuspected, but a careful examination usually reveals
a number of minute bodies adhering closely to the roots of the hair. When these are dis-
lodged and placed upon a white paper and viewed with a keen eye or magnifying glass, they
will be readily recognized as pediculi.
TREATiiE>'T. The blue mercurial ointment, which is a favorite lay remedy for this affec-
tion, is certainly efficacious, although objectionable. When freely applied it evokes an
eczema of the affected part. A sparing use of the ammoniated mercury ointment is far pref-
erable.
(204)
INDEX.
Au ; '. 13 follionlorum
Acafus Scabiei
Acne .
diagnosis of
treatment of
moUuscum
punctata albida
„ nigra
rosacea
sebacea .
Albinismus
Alligator boy
Alopecia
treatment of
Alopecia areata .
treatment of
Alpbos
Ambustio
Angioma .
treatment of
simplex
Anidrosis
Anthrax
Atrophia cutis
Atrophia pilorum
Barbadoes leg
Barbers itch
Bearded women
Black heads
Boil
Bromidrosis
treatment of
Burns
treatment of
Callositas .
treatment of
Canities
Carbunculus .
treatment of
Chicken pox .
Chilblain .
Chloasma
diagnosis of
treatment of
uterinum
Ohromidrosis
Chromopbytosis
rAsi
13
198
95
98
99
124
15
13
134
9
140
128
143
144
145
146
78
44
159
159
156
20
109
147
147
133
103
137
13
158
18
19
44
45
120
121
143
109
109
28
46
119
120
120
119
20
196
diagnosis of .
treatment of
Cicatrix
treatment of
Clavus .
treatment of
Comedo
diagnosis of
treatment of .
Condylomata acnminata
Condylomata lata .
Congelatio.
Corn
Cornua cutanea .
diagnosis of .
treatment of
Cow pox
Cyanidrosis . ,
Cystis sebacea
diagnosis of
treatment of .
Dandriff . . ,
Dermatalgia . ,
Dematitis . . ,
calorica .
traumatica .
venenata.
Dermatitis exfoliativa
diagnosis of .
treatment of
Eczema .
causes of
clinical forms of
diagnosis of
stages of
treatment of
erythematosum
ichorosum . .
marginatum .
papulosum .
pustulosum
rubrum
squamosum
vesiculosum
Eczema of the anus
treatment of
Eczema of the board
•AS»
197
197
140
149
121
121
13
14
14
122
122
46
121
126
127
12'
27
20
16
16
16
188
43
44
43
46
76
77
78
48
63
50
54
50
57
51
52
191
51
52
52
53
52
72
72
67
(205)
INDEX.
treatment of
Eczema of the ears
treatment of
Eczema of the face
treatment of
Eczema of the feet
treatment of
Eczema of the hands
truatmcnt of
Eczema of infants
diagnosis of
treatment of .
Eczema of the legs
treatment of .
Eczema of the scalp
treatment of .
Eczema of the scrotum
treatment of .
Eleplianiiasis
diagnosis of .
treatment of
grteeorum
Erythema simplex
diagnosis of .
treatment of
exfoliativuni .
Erythema intertrigo
treatment of .
Erythema multiforme
aunulatum
buUosum
diagnosis of
t refitment of
iris .
marginatum
nodosum
diagnosis of
treatment of
papulatum .
diagnosis of
treatment of
tuberculatum .
Erysipelas .
diagnosis of .
treatment of
Ephelis .
Epithelioma
treatment of .
Favus
treatment of .
Fibroma
diagnosis of .
treatment of
Fibroma roolluscom
Filaria sanguinis
Fire mark
Fish skin disease
Freckles
Frostbite .
rASK
67
Furnnculas . . .
08
diagnosis of
68
treatment of .
. 66
67
German measles
71
Gutta rosacea . .
71
69
71
Hematidrosis
62
Herpes ....
63
facialis
63
progenitalis . ,
73
treatment of
Herpes tonsurans .
65
Herpes zoster
66
Hirsuties
73
Hives
74
Hydroa ....
133
Hyperidrosis
. 134
treatment of .
134
Hypertrichosis .
. 176
causes of
30
treatment of
31
Hypertrophy of the nail
31
. 31
Ichthyosis
33
diagnosis of . .
33
treatment of
34
Impetigo contagiosa
35
Intertrigo .
37
Itch, the . . .
. 38
38
Keloid
. 35
diagnosis of .
35
treatment of
. 38
Keratosis pilaris .
39
treatment of
. 39
Kerion . . . .
34
. 36
Lentigo
36
treatment of .
. 34
Lepra ....
106
diagnosis of .
. 107
treatment of
107
Lepra arabum
. 118
Leprosy
180
Leucoderma .
. 182
treatment of
Lichen astivus
188
Lichen pilaris
. 190
Lichen planus
152
diagnosis of
. 154
treatment of .
154
Lichen ruber
. 152
treatment of .
134
Lichen scrofulosus
. 156
Lichen tropicus
127
Liver spot .
. 118
Lousiness . . •
45
Lues venerea
PAIIR
lod
108
108
22
134
20
UO
00
01
'.II
101
92
136
39
37
17
18
136
137
138
138
127
130
130
105
33
198
150
152
152
130
131
192
118
118
78, 176
178
178
133
176
141
142
84
130
85
86
86
86
88
88
84
119
200
167
(206)
Lupus erythematOBUs
diagnosis of .
treatment of .
Lupus vulgaris . ,
diagnosis of .
treatment of ,
Man-fish of Tennessee
Measles
Miliaria .
diagnosis of
treatment of .
Milium
diagnosis of .
treatment of
Milk crust
Molluscum . .
diagnosis of .
treatment of ,
Molluscum contagiosnm
Molluscum epitheliale
Jlolluscum fibrosum
Morbilli .
Morpbcea
diagnosis of
treatment of .
Naevus pigmentosas .
treatment of .
Naevus pilosus .
NiEvus spilus
Naevus vasculosus ,
treatment of .
Nrevus verrucosus
Nettle rash .
Neuralgia of the skin
Neuroma . ,
Onychatrophia .
Onychauxis .
treatment of
Onychia
treatment of
Onychomycosis ,
Osmidrosis.
Paronychia . ,
Pediculosis
Pcdiculus capitis .
" corporis
" pubis
Peliosis rheumatica
Pemphigus , .
diagnosis of
treatment of .
Pernio
Phtheiriasis capitis
treatment of
Plitheiiiasis corporia
treatment of
INDEX.
PAes
. 103
Phtheiriasis pubis .
164
treatment of
,
. 164
Pigmentary mole .
160
Pityriasis .
. 161
diagnosis of .
101
treatment of
Pityriasis rubra ,
. 128
" versicolor .
21
Porcupine men
. 84
Porrigo
84
diagnosis of .
84
treatment of
15
Porrigo decalvans.
15
Pox, the .
15
Pi-ickly heat .
. 52
Prurigo
124
diagnosis of .
. 125
treatment of
125
Pruritus
. 124
diagnosis of ,
124
treatment of .
. 152
Psoriasis .
21
diagnosis of ,
. 131
treatment of ,
132
Purpura
. 132
diagnosis of ,
treatment of . ,
117
hemorrhagica ,
. 117
' rheumatica . ,
117
. 117
156
. 157
117
Rhinoscleroma .
Rhus poisoning . ,
diagnosis of
39
treatment of .
Ringworm .
188
Rodent ulcer.
. 155
Rotheln
Rosacea.
148
treatment of
138
139
hvpertrophica
Rubella .
112
112
. 191
18
diagnosis of .
Rubeola
diagnosis of . .
112
Salt rheum
200
Sarcoma , . ,
. 200
diagnosis of
202
treatment of .
. 204
Scabies
115
diagnosis of . .
. 93
treatment of
04
Scar
. 95
Scarlatina .
46
diagnosis of .
, 200
Scarlet fever
201
Scleroderma .
. 2«2
diagnosis of
203
treatment of ,
.
rA«i
;iU4
204
117
75
:5
76
76
196
128
105
106
106
145
167
84
88
89
89
1«5
18(3
187
78
79
80
114
115
115
115
115
180
47
47
47
191
181
22
134
135
135
22
24
21
24
48
183
184
184
198
198
199
140
2-2
24
22
131
132
132
(207)
INDEX.
Scorbutus .
treatment of
Scurvy
Seborrhoea .
diagnosis of
treatment of
capitis
faciei
oleosa .
sicca
Shingles .
Small pox
Skin cancer
Steatozoon .
Strurao-derma .
Sunburn
Sycosis
diagnosis of ,
treatment of
Sycosis parasitica
Syphilis
treatment of
Telangiectasis .
diagnosis of
treatment of
Tetter, moist .
" dry
Tinea circinata
favoba
sycosis .
tonsurans .
trichuphytina ,
versicolor .
Toe-nail, ingrowing
Tricliauxesis
Trichophytosis
diaguosis of
treatment of
barbfi' .
capitiH
116
116
116
9
10
12
9
10
9
9
92
24
180
13
165
44
103
103
104
191
167
169
\bb
155
156
48
78
191
189
191
191
191
196
113
136
191
192
193
192
192
cruris . I , ,
UD um . . . .
Trichoi . i nodosa , .
Ulcer •
Ulcus . . . • .
treatment of . . ,
Urticaria ....
diagnosis of . . ,
etiology of . , ,
treatment of . . .
factitia ....
Vaccinia , . , . ,
Varicella . . • .
diagnosis of . . ,
Variola
diagnosis of . .
treatment of . . ,
Varioloid ....
Venereal wart . . .
Vernix caseosa . . .
Verruca .....
diagnosis of . .
treatment of . . ,
Vitiligo ....
Vitiligoidea ....
Wart
Wen
Wine mark . . .
Xanthelasma . . .
Xanthoma ....
diagnosis of . . .
treatment of .
Zoster
diagnosis of , .
treatment of .
UM
191
192
145
110
110
110
39
41
40
41
45
27
28
30
24
30
26
25
122
9
122
123
123
141
154
22
16
156
154
164
154
154
92
9a
93
(208)
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